Nursing Elites

1. A nurse is preparing to irrigate a client's indwelling catheter through a closed, intermittent system. Which of the following steps must the nurse take as part of this process?

• A. Use sterile solution at room temperature
• B. Position the client in a comfortable position
• C. Clamp the catheter at the level above the injection port
• D. Inject sterile solution through the injection port into the catheter

Correct answer: D

Rationale: When performing closed intermittent system catheter irrigation, the nurse should use sterile solution at room temperature with sterile technique. It is important to position the client comfortably for easy access to the catheter site and to assess the abdomen during the procedure. Clamping the catheter should be done below the level of the injection port, not above. The correct step is to inject sterile solution through the injection port into the catheter, allowing the fluid to travel up the catheter to irrigate the tubing and the bladder.

2. Which acronym would BEST describe the procedure for assessing a patient that appears unconscious?

• A. WBC
• B. QRS
• C. XYZ
• D. ABC

Correct answer: D

Rationale: The correct answer is D, 'ABC.' The ABC method stands for Airway, Breathing, Circulation. When encountering an unconscious patient, it is crucial to first ensure their Airway is clear by performing the 'head tilt, chin lift' maneuver. Next, assess Breathing by observing for chest rise and fall, listening for breath sounds, and feeling for airflow. Finally, check for Circulation by assessing for a pulse. Choices A, B, and C ('WBC,' 'QRS,' 'XYZ') are incorrect as they do not represent the standard approach to assessing an unconscious patient.

3. What should the nurse anticipate or expect of an American Indian woman seeking help to regulate her diabetes?

• A. Will comply with the treatment prescribed.
• B. Has given up her belief in naturalistic causes of disease.
• C. May also be seeking the assistance of a shaman or medicine man.
• D. Will need extra help in dealing with her illness and may be experiencing a crisis of faith.

Correct answer: C

Rationale: When caring for an American Indian patient seeking help for diabetes, the nurse should anticipate that the patient may also seek the assistance of a shaman or medicine man in addition to biomedical treatment. This cultural practice is common among American Indians who believe in holistic healing involving body, mind, and spirit. It is important for the nurse to acknowledge and respect these cultural beliefs and practices. Choice A is incorrect because patients from different cultures may not always comply with prescribed treatments due to various factors, including cultural beliefs. Choice B is incorrect as patients seeking traditional healing methods do not necessarily give up their beliefs in naturalistic causes of disease; instead, they often complement biomedical care. Choice D is incorrect as assuming the patient is experiencing a crisis of faith is not appropriate; it is more about respecting and understanding the patient's cultural background and beliefs.

4. Which technique of assessment will the healthcare provider use to determine the presence of crepitus, swelling, and pulsations?

• A. Palpation
• B. Inspection
• C. Percussion
• D. Auscultation

Correct answer: A

Rationale: Palpation involves using the sense of touch to assess various characteristics such as texture, temperature, moisture, organ location and size, as well as detecting swelling, pulsations, vibrations, rigidity, crepitus, lumps, masses, and tenderness or pain. In this scenario, the healthcare provider would utilize palpation to physically feel for crepitus, swelling, and pulsations. Inspection primarily relies on visual assessment, percussion involves assessing through palpable vibrations and audible sounds, and auscultation uses the sense of hearing. Therefore, the correct answer is palpation for assessing the presence of crepitus, swelling, and pulsations.

5. What is the primary purpose of emergency planning?

• A. Comply with the laws of the state.
• B. Comply with the laws of the U.S.
• C. Comply with both state and U.S. laws
• D. Maintain safety

Correct answer: D

Rationale: The primary purpose of emergency planning is to ensure and maintain the safety of people and the preservation of objects, such as buildings and personal possessions during emergencies or disasters. While compliance with state and federal laws regarding emergency planning is important, the main goal is to prioritize life and safety. Choices A, B, and C focus on legal compliance, which is necessary but secondary to the fundamental objective of safeguarding lives and property in emergency situations.

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