Nursing Elites

1. A nurse is preparing to perform closed intermittent bladder irrigation for a client following a transurethral resection of the prostate (TURP). Which of the following actions is appropriate by the nurse?

• A. Aspirate the irrigation solution from the bladder
• B. Insert the tip of the irrigation syringe into the catheter opening
• C. Apply sterile gloves
• D. Open the flow clamp to the irrigating fluid infusion tubing

Correct answer: C

Rationale: The correct action for the nurse to take before performing a closed intermittent bladder irrigation is to apply sterile gloves. Sterile gloves help maintain asepsis, reduce the risk of infection, and ensure patient safety during the procedure. Aspirating the irrigation solution from the bladder (Choice A) is not a standard step in closed intermittent bladder irrigation. Inserting the tip of the irrigation syringe into the catheter opening (Choice B) can introduce contaminants into the system. Opening the flow clamp to the irrigating fluid infusion tubing (Choice D) should only be done after ensuring all equipment is ready and the nurse is gloved to maintain sterility.

2. A healthcare provider is caring for a client prescribed amiodarone. Which of the following should the healthcare provider monitor?

• A. Liver function tests
• B. Serum potassium levels
• C. Blood pressure
• D. All of the above

Correct answer: D

Rationale: Amiodarone is known to potentially affect liver function, potassium levels, and blood pressure. Monitoring all these parameters regularly is crucial to detect any adverse effects early on. Liver function tests are necessary as amiodarone can cause hepatotoxicity. Serum potassium levels should be monitored due to the risk of hypokalemia or hyperkalemia with amiodarone use. Blood pressure monitoring is essential as amiodarone can cause hypotension or hypertension. Choosing 'All of the above' is the correct answer because all these parameters should be monitored to ensure the client's safety and well-being. Monitoring only one or two of these parameters may lead to missing important signs of adverse effects.

3. A nurse is planning care for four clients. Which client is the highest priority?

• A. Client with dry, black eschar on the heel
• B. Client wearing an arm cast and reporting numb fingers
• C. Client with reddened skin around the coccyx
• D. Client with frequent incontinence

Correct answer: B

Rationale: The correct answer is B because numb fingers indicate neurovascular compromise, which can lead to serious complications if not addressed promptly. The priority in this situation is to assess and address any circulation issues affecting the extremity. Choices A, C, and D are of concern but not as immediate as neurovascular compromise, which requires urgent attention to prevent further complications.

4. A nurse is caring for a client who has schizophrenia. Which of the following assessment findings should the nurse expect?

• A. Decreased level of consciousness
• B. Inability to identify common objects
• C. Poor problem-solving ability
• D. Preoccupation with somatic disturbances

Correct answer: C

Rationale: In clients with schizophrenia, poor problem-solving ability is a common assessment finding due to impaired cognitive function associated with the disorder. This impairment can manifest as difficulties in decision-making and problem-solving. Choice A, decreased level of consciousness, is not a typical finding in schizophrenia. Choice B, inability to identify common objects, is more indicative of conditions like dementia rather than schizophrenia. Choice D, preoccupation with somatic disturbances, is more characteristic of somatic symptom disorder rather than schizophrenia.

5. While caring for a newborn under phototherapy lights, what is an appropriate nursing action?

• A. Ensure an eye shield is covering the eyes
• B. Apply lotion to the exposed skin
• C. Offer glucose water between feedings
• D. Discontinue breastfeeding during treatment

Correct answer: A

Rationale: The correct answer is to ensure an eye shield is covering the eyes. This action is essential to protect the newborn's eyes from the bright light used in phototherapy. Applying lotion to the exposed skin (Choice B) is not necessary and may interfere with the treatment. Offering glucose water between feedings (Choice C) is not indicated and may not be appropriate for a newborn undergoing phototherapy. Discontinuing breastfeeding during treatment (Choice D) is not recommended as breastfeeding should be continued unless contraindicated.

Similar Questions