Nursing Elites

1. When using an open irrigation technique to irrigate a client's indwelling urinary catheter, which of the following actions should the nurse take?

• A. Place the client in a side-lying position
• B. Instill 15 mL of irrigation fluid into the catheter with each flush
• C. Subtract the amount of irrigant used from the client's urine output
• D. Perform the irrigation using a 20 mL syringe

Correct answer: C

Rationale: The correct action for the nurse to take when using an open irrigation technique on a client with an indwelling urinary catheter is to subtract the amount of irrigant used from the client's urine output. This calculation helps ensure an accurate measurement of the client's actual urine output by accounting for the irrigation fluid introduced into the catheter. Placing the client in a side-lying position (Choice A) is not directly related to the irrigation procedure. Instilling a specific volume of irrigation fluid (Choice B) may vary depending on the client's condition and the healthcare provider's order. Using a 20 mL syringe for irrigation (Choice D) is a matter of equipment choice and does not directly impact the calculation of urine output in this context.

2. When evaluating a client's use of a cane, which action should the nurse identify as an indication of correct use?

• A. The client's stronger side holds the cane
• B. The top of the cane is parallel to the client's waist
• C. The client holds the cane on the stronger side of their body
• D. The client moves the cane 46 cm (18 in) forward

Correct answer: C

Rationale: The correct way to use a cane is to hold it on the stronger side of the body. This helps to provide support and maintain alignment. Option A is incorrect because the cane should be held on the stronger side, not the weaker side. Option B is incorrect as the top of the cane should be at the level of the greater trochanter, not the waist. Option D is incorrect because the client should move the weaker limb forward with the cane for stability.

3. A client needs to maintain a positive nitrogen balance for wound healing. Which of the following food items should the nurse recommend as a good source of complete protein?

• A. Cheddar cheese
• B. White rice
• C. Apples
• D. Green beans

Correct answer: A

Rationale: Cheddar cheese is the correct answer as it is a good source of complete protein that contains all essential amino acids required for maintaining a positive nitrogen balance for wound healing. Complete proteins provide all essential amino acids needed by the body. White rice, apples, and green beans do not offer complete proteins like cheddar cheese, making them inadequate choices for this purpose.

4. A healthcare professional is planning to collect a liquid stool specimen from a client for ova and parasites. Inaccurate test results may result if the healthcare professional:

• A. Refrigerates the collected specimen
• B. Collects the specimen in a sterile container
• C. Delays the collection of the specimen
• D. Uses a non-contaminated collection container

Correct answer: A

Rationale: Refrigeration can kill the ova and parasites present in the stool specimen, leading to inaccurate test results. Storing the specimen in a cold environment can disrupt the integrity of the parasites and ova, affecting the accuracy of the test. Collecting the specimen in a sterile container (Choice B) is the correct procedure to prevent external contamination. Delaying the collection of the specimen (Choice C) may affect the freshness of the sample but does not directly impact the test results. Using a non-contaminated collection container (Choice D) is essential to maintain the sample's integrity but does not relate to the risk of killing ova and parasites through refrigeration.

5. A healthcare professional is reviewing a client's fluid and electrolyte status. Which of the following findings should the healthcare professional report to the provider?

• A. BUN 15 mg/dL
• B. Creatinine 0.8 mg/dL
• C. Sodium 143 mEq/L
• D. Potassium 5.4 mEq/L

Correct answer: D

Rationale: The correct answer is D. A potassium level of 5.4 mEq/L is above the expected reference range, indicating hyperkalemia. Hyperkalemia can lead to serious complications such as dysrhythmias, making it important for the healthcare professional to report this finding to the provider for further evaluation and intervention. Choices A, B, and C fall within normal ranges and do not pose an immediate risk to the client's health, so they would not warrant immediate reporting to the provider. Elevated BUN or creatinine levels may indicate kidney dysfunction, while a sodium level of 143 mEq/L falls within the normal range for adults and does not typically require urgent intervention.

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