Nursing Elites

1. A healthcare professional reviews a client’s laboratory results. Which results from the client’s urinalysis should the healthcare professional identify as normal? (Select all that apply.)

• A. pH: 6
• B. Specific gravity: 1.015
• C. Glucose: negative
• D. All of the above

Correct answer: D

Rationale: In a urinalysis, a pH of 6 is within the normal range (typically between 4.6 and 8); a specific gravity of 1.015 is considered normal (usually ranging between 1.005 to 1.030); and a negative glucose result is also normal. Therefore, choices A, B, and C are correct as they fall within the normal values for a urinalysis. Choices A, B, and C are the correct answers, as the pH, specific gravity, and glucose levels are within the normal range for a urinalysis. Choice D is correct because all the listed values are normal. Choices A, B, and C are the correct options as they meet the criteria for normal urinalysis values. The other choices do not fall within the normal range for a urinalysis.

2. After checking the urinary drainage system for kinks in the tubing, the nurse determines that a client who has returned from the post-anesthesia care has a dark, concentrated urinary output of 54 ml for the last 2 hours. What priority nursing action should be implemented?

• A. Report the findings to the surgeon.
• B. Irrigate the indwelling urinary catheter.
• C. Apply manual pressure to the bladder.
• D. Increase the IV flow rate for 15 minutes.

Correct answer: A

Rationale: In this situation, the nurse's priority action should be to report the findings to the surgeon. An adult should typically produce about 60 ml of urine per hour, so a dark, concentrated, and low urine output of 54 ml over 2 hours raises concerns. This change in urine output may indicate issues such as dehydration, renal problems, or inadequate fluid intake. Reporting this finding to the surgeon is crucial to ensure appropriate evaluation and intervention. Irrigating the catheter, applying manual pressure to the bladder, or increasing the IV flow rate are not appropriate actions based on the information provided and could potentially worsen the situation.

3. After pericardiocentesis for cardiac tamponade, for which signs should the nurse assess the client to determine if tamponade is recurring?

• A. Decreasing pulse
• B. Rising blood pressure
• C. Distant muffled heart sounds
• D. Falling central venous pressure (CVP)

Correct answer: C

Rationale: After pericardiocentesis for cardiac tamponade, the nurse should assess for distant muffled heart sounds that were noted before the procedure. If these sounds return, it could indicate recurring pericardial effusion and potential tamponade. Therefore, the correct answer is the return of distant muffled heart sounds (Option C). Decreasing pulse (Option A) and falling central venous pressure (Option D) are not specific signs of recurring tamponade. Rising blood pressure (Option B) is also not a typical sign of tamponade recurrence; in fact, hypotension is more commonly associated with tamponade.

4. A client admitted from a nursing home after several recent falls needs a urine sample for culture and sensitivity. What should the nurse complete first?

• A. Obtain urine sample for culture and sensitivity.
• B. Administer intravenous antibiotics.
• C. Encourage protein intake and additional fluids.
• D. Consult physical therapy for gait training.

Correct answer: A

Rationale: In this scenario, the priority intervention is to obtain a urine sample for culture and sensitivity. Older adults with recent falls may have atypical symptoms of urinary tract infection (UTI), which can present as new-onset confusion or falling. It is crucial to rule out UTI before initiating antibiotics. While administering antibiotics, encouraging protein intake, fluids, and consulting physical therapy are important interventions, they should follow the urine sample collection to ensure accurate diagnosis and appropriate treatment.

5. A client scheduled for the surgical creation of an ileal conduit expresses anxiety and asks about having a drainage tube. How should the nurse respond?

• A. I will ask the provider to prescribe you an antianxiety medication.
• B. Would you like to discuss the procedure with your doctor once more?
• C. I think it would be nice to not have to worry about finding a bathroom.
• D. Would you like to speak with someone who has an ileal conduit?

Correct answer: D

Rationale: The most appropriate response for the nurse is to offer the client the opportunity to speak with someone who has undergone the same procedure. This allows the client to gain insight, ask questions, and share concerns with someone who has firsthand experience, which can help alleviate anxiety and promote a positive self-image. Seeking an antianxiety medication does not address the client's emotional concerns or promote a positive attitude towards the procedure. Discussing the procedure with the doctor again may provide more information but may not offer the same level of emotional support and understanding as speaking with someone who has lived through the experience. Commenting on the convenience of not having to search for a bathroom minimizes the client's anxiety and overlooks the emotional aspect of the client's concerns.

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