Nursing Elites

1. A client is taught how to collect a 24-hour urine specimen. Which statement indicates understanding of the procedure?

• A. I should keep the urine specimen refrigerated.
• B. I need to start the collection in the morning after my first void.
• C. I will collect the urine for 24 hours and keep it on ice.
• D. I will start collecting the urine after discarding my first morning specimen.

Correct answer: D

Rationale: The correct way to collect a 24-hour urine specimen is to discard the first morning void and then start the collection. Choice A is incorrect because refrigeration is not typically necessary for a 24-hour urine specimen. Choice B is incorrect as the client needs to discard the first void. Choice C is incorrect; while collecting urine for 24 hours is correct, keeping it on ice is not standard procedure.

2. When caring for a laboring client whose contractions are occurring every 2 to 3 min, the nurse should document that the pump is infusing how many ml/hr?

• A. 42
• B. 50
• C. 60
• D. 70

Correct answer: A

Rationale: To calculate the infusion rate, we first need to determine the frequency of contractions per hour. If contractions are occurring every 2 to 3 minutes, this corresponds to 20 to 30 contractions in an hour (60 minutes). The average is 25 contractions in an hour. The pump should be infusing 1 ml for each contraction, so the infusion rate should be 25 ml/hr. Therefore, the correct answer is 42 ml/hr. Choices B, C, and D are incorrect as they do not align with the calculation based on the given data.

3. A 20-year-old female client tells the nurse that her menstrual periods occur about every 28 days, and her breasts are quite tender when her menstrual flow is heavy. She also states that she performs her breast self-examination (BSE) on the first day of every month. What action should the nurse implement in response to the client's statements?

• A. Remind the client that it is also important to schedule an annual mammogram
• B. Refer the client to a nurse practitioner for an in-depth review of the BSE procedure
• C. Encourage the client to perform BSE 2 to 3 days after the menstrual period ends
• D. Instruct the client to continue with her regular monthly exams as she is doing

Correct answer: C

Rationale: The correct response is to encourage the client to perform breast self-examination (BSE) 2 to 3 days after her menstrual period ends. This timing is important because breasts are least tender during this phase of the menstrual cycle, allowing for a more effective examination. Choice A is incorrect because while scheduling an annual mammogram is important, the immediate concern is the timing of BSE. Choice B is incorrect as the client's BSE practice just needs a slight adjustment in timing, not an in-depth review. Choice D is incorrect as the client should perform BSE when her breasts are least tender for optimal detection of any abnormalities.

4. A 20-year-old male client is diagnosed with Ewing's sarcoma following examination for a knee injury. Which instruction is most important for the nurse to provide the client?

• A. Take analgesics regularly to reduce the pain
• B. Notify the healthcare provider if the swelling worsens
• C. Avoid weight-bearing until the injury heals
• D. Seek treatment for the sarcoma immediately

Correct answer: D

Rationale: The correct answer is to instruct the client to seek treatment for the sarcoma immediately. Ewing's sarcoma is an aggressive cancer, and prompt treatment is crucial for improving prognosis. Option A is incorrect because while pain management is important, addressing the underlying cause (sarcoma) is the priority. Option B is not as critical as seeking treatment for the sarcoma itself. Option C is not the most important instruction as the primary concern is addressing the cancer diagnosis.

5. Is it necessary to continue to strain the urine of a client with kidney stones since several stones were obtained the previous day?

• A. UAPs should follow the prescribed care without questioning it
• B. Yes, it is important to continue straining all the client's urine
• C. Measuring intake and output is equally important as straining the urine
• D. Ensuring that the client is free from pain should be the top priority

Correct answer: B

Rationale: Yes, it is important to continue straining all urine to catch any remaining stones. Straining the urine helps in identifying any new stones that may have formed, allowing for appropriate management. While measuring intake and output is important, straining the urine is specifically necessary in this case to monitor the presence of kidney stones. Ensuring the client is free from pain is essential, but in this situation, preventing further complications related to kidney stones is a higher priority.

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