Nursing Elites

1. A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 ml/hr. What intervention should the nurse anticipate?

• A. Clamp the catheter.
• B. Administer a fluid bolus.
• C. Obtain a urine specimen for culture and sensitivity.
• D. Initiate continuous bladder irrigation.

Correct answer: D

Rationale: In this scenario, the nurse should anticipate initiating continuous bladder irrigation. Dark yellow urine output at a rate of 25 ml/hr following abdominal surgery may indicate urinary stasis or obstruction, which could lead to complications like urinary retention. Continuous bladder irrigation helps prevent catheter obstruction and manage urinary retention by ensuring patency and promoting urine flow. Clamping the catheter (Choice A) could lead to urinary stasis and should be avoided. Administering a fluid bolus (Choice B) is not indicated solely based on the urine color and output described. Obtaining a urine specimen for culture and sensitivity (Choice C) may be necessary for assessing infection but does not directly address the issue of urinary stasis or obstruction.

2. A nurse is caring for a client who is receiving chemotherapy. Which of the following findings should the nurse report to the provider?

• A. Alopecia
• B. Weight gain of 1 kg (2.2 lb) in 24 hours
• C. White blood cell count of 6,000/mm³
• D. Temperature of 37.2°C (99°F)

Correct answer: B

Rationale: The correct answer is B. A weight gain of 1 kg (2.2 lb) in 24 hours is concerning as it indicates fluid retention, which can be a sign of complications in clients receiving chemotherapy. Rapid weight gain can be associated with conditions like fluid overload or electrolyte imbalances, which need prompt medical attention. Choices A, C, and D are not typically immediate concerns related to chemotherapy. Alopecia (choice A) is a common side effect of chemotherapy, a white blood cell count of 6,000/mm³ (choice C) falls within the normal range, and a temperature of 37.2°C (99°F) (choice D) is slightly elevated but not a critical finding in this context.

3. A nurse is caring for a client who is receiving warfarin therapy. Which of the following laboratory results indicates the need for an increase in the dose of warfarin?

• A. PT 28 seconds
• B. INR 1.2
• C. aPTT 40 seconds
• D. Fibrinogen 350 mg/dL

Correct answer: B

Rationale: An INR of 1.2 is below the therapeutic range for a client on warfarin, indicating inadequate anticoagulation. Therefore, the client would require an increase in the dose of warfarin to achieve the desired therapeutic effect. Choices A, C, and D are not indicative of the need for a dose increase in warfarin therapy. PT of 28 seconds is within the therapeutic range, aPTT of 40 seconds is also within the normal range, and fibrinogen level of 350 mg/dL does not provide information about the anticoagulant effect of warfarin.

4. A nurse is caring for a client who is 1 hr postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take?

• A. Irrigate the catheter with 0.9% sodium chloride.
• B. Reposition the catheter.
• C. Notify the provider.
• D. Increase the rate of the continuous bladder irrigation.

Correct answer: A

Rationale: In this situation, the nurse should irrigate the catheter with 0.9% sodium chloride to help relieve any obstruction and ensure proper urinary drainage following a TURP. Repositioning the catheter may not address the underlying issue of obstruction. Notifying the provider should be done after attempting to resolve the drainage issue. Increasing the rate of continuous bladder irrigation is not the initial intervention for a catheter that is not draining.

5. A client with a new diagnosis of type 1 diabetes mellitus is being taught by a nurse. Which of the following client statements indicates an understanding of the teaching?

• A. I will check my blood glucose levels only when I feel sick.
• B. I will inject insulin in the same spot each time.
• C. I will rotate injection sites within the same anatomical region.
• D. I will inject insulin only if my blood glucose level is above 200 mg/dL.

Correct answer: C

Rationale: The correct answer is C. Clients with type 1 diabetes should rotate injection sites within the same anatomical region to prevent lipodystrophy. Choice A is incorrect because blood glucose levels should be checked regularly, not only when feeling sick. Choice B is incorrect as injecting insulin in the same spot each time can lead to lipodystrophy. Choice D is incorrect as insulin injections are usually required based on meal schedules and blood glucose levels, not just when levels are above 200 mg/dL.

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