Nursing Elites

1. 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.

2. An adult who was recently diagnosed with glaucoma tells the nurse, 'it feels like I am driving through a tunnel.' The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide this client?

• A. Maintain prescribed eye drop regimen
• B. Avoid frequent eye pressure measurements
• C. Wear prescription glasses
• D. Eat a diet high in carotene

Correct answer: A

Rationale: The correct answer is A: Maintain prescribed eye drop regimen. In glaucoma, maintaining the prescribed eye drop regimen is crucial for controlling intraocular pressure, which helps in preventing vision loss. Consistent use of eye drops as directed can slow down the progression of the disease and preserve vision. Choice B is incorrect because avoiding frequent eye pressure measurements does not address the primary treatment for glaucoma. Choice C is incorrect as wearing prescription glasses may be helpful for vision correction but does not directly address the management of glaucoma. Choice D is incorrect because while a diet high in carotene may promote overall eye health, it is not the most important instruction for managing glaucoma.

3. When preparing to examine a client’s skin using a Wood light, what should the nurse do to facilitate this procedure?

• A. Darken the examining room
• B. Administer a local anesthetic
• C. Obtain a signed informed consent
• D. Shave the skin and scrub it with povidone-iodine (Betadine)

Correct answer: A

Rationale: When using a Wood light to examine the skin, the nurse should darken the examining room. This is necessary because the Wood light emits long-wavelength UV light, which is better visualized in a darkened environment. Administering a local anesthetic (Choice B) is not needed for this procedure. Obtaining a signed informed consent (Choice C) is not directly related to using a Wood light for skin examination. Shaving the skin and scrubbing it with povidone-iodine (Betadine) (Choice D) is not required and may not be appropriate for this type of skin examination.

4. A client with a family history of polycystic kidney disease (PKD is being assessed by a nurse. For which clinical manifestations should the nurse assess? (Select all that apply.)

• A. Nocturia
• B. Flank pain
• C. Increased abdominal girth
• D. B & C

Correct answer: D

Rationale: Clients with PKD commonly present with flank pain and increased abdominal girth due to abdominal distention caused by cysts. Bloody urine is also a common symptom due to tissue damage from PKD. Nocturia and dysuria are not typical manifestations of PKD. Constipation is not directly associated with PKD. Therefore, the correct choices are flank pain and increased abdominal girth, making option D the correct answer.

5. A client has just had a central line catheter placed that is specific for hemodialysis. What is the most appropriate action by the nurse?

• A. Use the catheter for the next laboratory blood draw.
• B. Monitor the central venous pressure through this line.
• C. Access the line for the next intravenous medication.
• D. Place a heparin or heparin/saline dwell after hemodialysis.

Correct answer: D

Rationale: The most appropriate action for the nurse after a central line catheter placement for hemodialysis is to place a heparin or heparin/saline dwell after hemodialysis treatment. This helps prevent clot formation in the line and maintain patency for future use. Using the catheter for blood draws is not recommended as it may increase the risk of infection. Monitoring central venous pressure is not indicated with this type of catheter. Accessing the line for medications is also not recommended to prevent complications and ensure the line is solely used for hemodialysis purposes.

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