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 nurse is assessing a client who has Clostridium difficile (C. diff) infection. Which infection control measure should the nurse implement?

• A. Wear a face shield when entering the room
• B. Place the client in a private room
• C. Place the client in a negative pressure room
• D. Use alcohol-based hand rub following client care

Correct answer: B

Rationale: The correct answer is to place the client in a private room. Clostridium difficile (C. diff) infection requires contact precautions, which include isolating the client in a private room to prevent the spread of infection to others. Wearing a face shield may be necessary in certain situations for protection but is not the primary measure for C. diff. Placing the client in a negative pressure room is not specifically indicated for C. diff unless the client has additional respiratory issues. Using alcohol-based hand rub following client care is not sufficient for C. diff control; thorough handwashing with soap and water is recommended due to the spore-forming nature of C. diff.

3. A healthcare professional is assessing a client in the PACU. Which finding indicates decreased cardiac output?

• A. Shivering
• B. Oliguria
• C. Bradypnea
• D. Constricted pupils

Correct answer: B

Rationale: The correct answer is B: Oliguria. Oliguria (low urine output) is a sign of decreased cardiac output because the kidneys are not receiving enough blood to produce an adequate amount of urine. Shivering (choice A) is a response to hypothermia or the body's attempt to generate heat. Bradypnea (choice C) refers to abnormally slow breathing rate and is not directly related to cardiac output. Constricted pupils (choice D) are more indicative of conditions affecting the nervous system or medications.

4. A nurse is preparing to administer an intramuscular injection to an adult client. At what angle should the nurse administer the medication using the ventrogluteal site?

• A. 90-degree angle
• B. 60-degree angle
• C. 75-degree angle
• D. 45-degree angle

Correct answer: A

Rationale: The correct answer is A: 90-degree angle. The ventrogluteal site is preferred for intramuscular injections because it is away from major nerves and blood vessels. Administering the injection at a 90-degree angle ensures that the medication reaches deep into the muscle tissue, allowing for proper absorption of the drug. Choice B, 60-degree angle, is incorrect as it is not the recommended angle for the ventrogluteal site. Choice C, 75-degree angle, and Choice D, 45-degree angle, are also incorrect as they are not the appropriate angles for administering an intramuscular injection using the ventrogluteal site.

5. A patient is receiving discharge teaching for esophageal cancer and starting radiation therapy. What instruction should the healthcare provider include?

• A. Remove dye markings after each radiation treatment
• B. Apply a warm compress to the irradiated site
• C. Wear clothing over the area of radiation treatment
• D. Use a washcloth to bathe the treatment area

Correct answer: C

Rationale: The correct instruction for a patient starting radiation therapy for esophageal cancer is to wear clothing over the area of radiation treatment. This helps to prevent irritation and protect the skin. Removing dye markings after each treatment (choice A) is unnecessary and not typically part of the patient's self-care. Applying a warm compress (choice B) can exacerbate skin irritation caused by radiation. Using a washcloth to bathe the treatment area (choice D) can potentially irritate the skin further, making it important to avoid.

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