Nursing Elites

1. A client has an indwelling urinary catheter. Which of the following assessment findings indicates that the catheter requires irrigation?

• A. Bladder scan shows 525 mL of urine
• B. Urine has a strong odor
• C. The client reports abdominal discomfort
• D. The catheter is blocked or not draining

Correct answer: D

Rationale: The correct answer is D because if the catheter is blocked or not draining, it may need irrigation to restore proper flow. Option A, 'Bladder scan shows 525 mL of urine,' does not necessarily indicate the need for irrigation as it could be within the expected range for catheter drainage. Option B, 'Urine has a strong odor,' may indicate a urinary tract infection but does not directly correlate with the need for catheter irrigation. Option C, 'The client reports abdominal discomfort,' could indicate various issues but does not specifically suggest the need for catheter irrigation.

2. A healthcare professional is caring for a client who has a prescription for morphine 5mg IM but accidentally administers the entire 10mg from the single-dose vial. Which of the following actions should the healthcare professional take first?

• A. Complete an incident report
• B. Measure the client’s respiratory rate
• C. Report the incident to the pharmacy
• D. Notify the client's provider

Correct answer: B

Rationale: Assessing the client's respiratory rate is the priority in this situation as overdosing on morphine can lead to respiratory depression, making it crucial to monitor the client's breathing. Completing an incident report (choice A) is important but should not be the first action. Reporting the incident to the pharmacy (choice C) and notifying the client's provider (choice D) are necessary steps but assessing the client's respiratory status takes precedence to ensure immediate safety and intervention.

3. An older adult client at risk for osteoporosis is being taught by a nurse about starting a regular physical activity program. Which type of activity should the nurse recommend?

• A. Walking briskly
• B. Riding a bicycle
• C. Performing isometric exercises
• D. Engaging in high-impact aerobics

Correct answer: A

Rationale: The correct answer is walking briskly. Weight-bearing exercises, such as brisk walking, are recommended for individuals at risk for osteoporosis because they help maintain bone mass and prevent bone loss. Riding a bicycle and performing isometric exercises are not weight-bearing activities, and therefore, may not provide the same bone-strengthening benefits as walking. High-impact aerobics can increase the risk of fractures in individuals with osteoporosis due to the high level of impact involved.

4. When evaluating a client's use of a cane, which action should the nurse identify as an indication of correct use?

• A. The client's stronger side holds the cane
• B. The top of the cane is parallel to the client's waist
• C. The client holds the cane on the stronger side of their body
• D. The client moves the cane 46 cm (18 in) forward

Correct answer: C

Rationale: The correct way to use a cane is to hold it on the stronger side of the body. This helps to provide support and maintain alignment. Option A is incorrect because the cane should be held on the stronger side, not the weaker side. Option B is incorrect as the top of the cane should be at the level of the greater trochanter, not the waist. Option D is incorrect because the client should move the weaker limb forward with the cane for stability.

5. A client has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure.

• A. Inject 5 units of air into the bottle of regular insulin
• B. Withdraw the correct dose of NPH insulin from the bottle
• C. Inject 10 units of air into the bottle of NPH insulin
• D. Withdraw the correct dose of regular insulin from the bottle

Correct answer: B

Rationale: The correct order of steps for this procedure is to first inject air into the NPH insulin bottle to prevent vacuum formation. After injecting air into the NPH insulin, the next step is to withdraw the correct dose of regular insulin from its bottle. This sequence ensures that the regular insulin is drawn after the NPH insulin, preventing contamination and ensuring accurate dosing. Therefore, choice B is correct. Choices A, C, and D are incorrect because air should be injected into the NPH insulin first, not the regular insulin, and the doses should be withdrawn in the appropriate order to maintain the integrity and potency of each insulin type.

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