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. Which statement by the mother indicates that the mother understands safety precautions with her four-month-old infant and her 4-year-old child?

• A. I secure the infant car seat in the back seat facing backwards.
• B. I place my infant in the middle of the living room floor on a blanket to play with my 4-year-old while I make supper in the kitchen.
• C. My sleeping baby looks adorable in the crib with the little buttocks up in the air while the four-year-old naps on the sofa.
• D. I have the 4-year-old hold and help feed the four-month-old a bottle in the kitchen while I make supper.

Correct answer: D

Rationale: Choice D is the correct answer because having the 4-year-old help feed the four-month-old a bottle in the kitchen while the mother makes supper shows supervision of the infant by the older child in a safe environment. This choice indicates that the mother understands safety precautions by involving the older child in a caregiving task under her supervision. Choices A, B, and C are incorrect because they involve unsafe practices such as placing the infant on the floor unsupervised, positioning the infant car seat in the front seat, and not providing direct supervision of the children during naptimes.

3. After preparing and lubricating the enema set, what is the correct sequence of steps a nurse should follow when administering a large volume enema to a client?

• A. Administer the enema solution.
• B. Remove the enema tube from the client's rectum.
• C. Wrap the end of the enema tube with a disposable tissue.
• D. Insert the enema tube into the client's rectum.

Correct answer: B

Rationale: The correct sequence for administering a large volume enema is as follows: 1. Insert the enema tube into the rectum, 2. Administer the enema solution, 3. Clamp the tube, 4. Remove the tube, 5. Wrap the end with tissue. Therefore, the nurse should remove the enema tube from the client's rectum after administering the enema solution. Choices A, C, and D are incorrect because the enema tube should be removed from the rectum after the administration of the solution, not before or during the process.

4. A client is 1-day postoperative and reports a pain level of 10 on a scale of 0 to 10. After reviewing the client’s medication administration record, which of the following medications should be administered?

• A. Meperidine 75 mg IM
• B. Fentanyl 50 mcg/hr transdermal patch
• C. Morphine 2 mg IV
• D. Oxycodone 10 mg PO

Correct answer: C

Rationale: Morphine IV is the most appropriate choice for severe postoperative pain due to its rapid onset and effectiveness. Meperidine is not preferred due to its potential side effects, and fentanyl patches are typically used for chronic pain, not acute postoperative pain. Oxycodone taken orally is not ideal for providing immediate relief in this situation.

5. After a client's death in a long-term care facility, identify the correct sequence of steps for the nurse to perform.

• A. 1) Place a name tag on the body 2) Obtain the pronouncement of death from the provider 3) Remove tubes and indwelling lines 4) Wash the client's body 5) Ask the client's family members if they would like to view the body
• B. 2) Obtain the pronouncement of death from the provider 3) Remove tubes and indwelling lines 4) Wash the client's body 5) Ask the client's family members if they would like to view the body 1) Place a name tag on the body
• C.
• D.

Correct answer: B

Rationale: The correct sequence of steps for the nurse in a long-term care facility after a client's death is as follows: First, obtain the pronouncement of death from the provider. Second, remove tubes and indwelling lines before proceeding to wash the client's body. Third, ask the client's family members if they would like to view the body. Finally, place a name tag on the body. This order ensures that the necessary procedures are followed with respect and consideration for the deceased client and their family. Choice B is correct. Choices A, C, and D are incorrect as they do not follow the appropriate sequence of actions required in this situation.

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