Nursing Elites

1. A nurse is caring for a client with an indwelling urinary catheter. Which intervention is most important to include in the client's plan of care?

• A. Ensure the catheter is below the level of the bladder at all times.
• B. Change the catheter bag every 48 hours.
• C. Cleanse the perineal area daily.
• D. Perform catheter care daily.

Correct answer: A

Rationale: The correct answer is to ensure the catheter is always below the level of the bladder. Placing the catheter tubing above the level of the bladder can lead to backflow of urine, causing urinary tract infections. Changing the catheter bag every 48 hours is important but not as crucial as maintaining proper catheter positioning. Cleaning the perineal area daily and performing catheter care are essential tasks but do not directly address the prevention of complications associated with catheter placement.

2. A client with rheumatoid arthritis is prescribed methotrexate. Which laboratory value should the nurse monitor closely?

• A. White blood cell count of 10,000/mm³
• B. Hemoglobin of 12 g/dL
• C. Liver function tests
• D. Platelet count of 150,000/mm³

Correct answer: C

Rationale: The correct answer is C: Liver function tests. Methotrexate can cause hepatotoxicity, making it essential to closely monitor liver function tests in clients receiving this medication. Monitoring white blood cell count, hemoglobin, or platelet count is not specifically required for methotrexate therapy and would not provide relevant information regarding potential adverse effects of the medication.

3. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which finding indicates the need for immediate intervention?

• A. Use of accessory muscles
• B. Oxygen saturation of 94%
• C. Carbon dioxide level of 45 mmHg
• D. Respiratory rate of 20 breaths per minute

Correct answer: C

Rationale: A carbon dioxide level of 45 mmHg is concerning in a client with COPD receiving supplemental oxygen, as it may indicate carbon dioxide retention and requires immediate intervention. Options A, B, and D are not the priority findings in this scenario. While the use of accessory muscles, an oxygen saturation of 94%, and a respiratory rate of 20 breaths per minute are important to monitor in a client with COPD, they do not indicate an immediate need for intervention like an elevated carbon dioxide level does.

4. A client with a tracheostomy has thick, tenacious secretions. Which intervention should the nurse implement first?

• A. Perform deep suctioning every 2 to 4 hours.
• B. Encourage the client to drink plenty of fluids.
• C. Increase humidity in the client's room.
• D. Administer a mucolytic agent.

Correct answer: C

Rationale: Increasing humidity in the client's room can help liquefy thick secretions and facilitate easier airway clearance in a client with a tracheostomy. This intervention should be implemented first as it is non-invasive and can often effectively address the issue of thick secretions. Performing deep suctioning (Choice A) should not be the first intervention as it is more invasive and should be done based on assessment findings. Encouraging the client to drink plenty of fluids (Choice B) is beneficial but may not provide immediate relief for thick secretions. Administering a mucolytic agent (Choice D) requires a healthcare provider's prescription and should be based on assessment data and the client's condition.

5. A 35-year-old female client has just been admitted to the post-anesthesia recovery unit following a partial thyroidectomy. Which statement reflects the nurse's accurate understanding of the expected outcome for the client following this surgery?

• A. Supplemental hormonal therapy will probably be unnecessary.
• B. The thyroid will regenerate to a normal size within a few years.
• C. The client will be restricted from eating seafood.
• D. The remainder of the thyroid will be removed at a later date.

Correct answer: C

Rationale: After a partial thyroidectomy, the client may be advised to avoid eating seafood due to its high iodine content, which can affect the thyroid function. Choice A is incorrect because after a partial thyroidectomy, supplemental hormonal therapy may be necessary. Choice B is incorrect as the thyroid does not regenerate after a partial thyroidectomy. Choice D is incorrect; the remaining portion of the thyroid is not typically removed at a later date unless there are specific medical reasons to do so.

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