Nursing Elites

1. What action should the nurse take after applying gloves to irrigate a client's indwelling urinary catheter using an open technique?

• A. Empty the client's urinary drainage bag.
• B. Draw up the irrigating solution into the syringe.
• C. Secure the client's catheter to the drainage tubing.
• D. Use aseptic technique to instill the irrigating solution.

Correct answer: B

Rationale: After applying gloves to irrigate an indwelling urinary catheter using an open technique, the next step for the nurse is to draw up the irrigating solution into the syringe. This step is crucial as it ensures that the solution is ready to be instilled through the catheter to maintain its patency and prevent blockages. Option A is incorrect as emptying the client's urinary drainage bag is not the immediate next step in the irrigation process. Option C is incorrect as securing the client's catheter to the drainage tubing is not necessary at this stage. Option D is incorrect as the question pertains to the action immediately after applying gloves and does not involve instilling the irrigating solution yet.

2. What intervention should the healthcare provider include in the plan of care for a client receiving treatment with an Unna's paste boot for leg ulcers due to chronic venous insufficiency?

• A. Check capillary refill of toes on the lower extremity with the Unna's paste boot.
• B. Apply dressing to the wound area before applying the Unna's paste boot.
• C. Wrap the leg from the knee down towards the foot.
• D. Remove the Unna's paste boot every 8 hours to assess wound healing.

Correct answer: A

Rationale: When an Unna's paste boot is applied for leg ulcers due to chronic venous insufficiency, it is crucial to check the capillary refill of the toes on the lower extremity to ensure adequate circulation. The Unna's paste boot can become rigid after drying, potentially affecting circulation distally. Monitoring capillary refill helps assess the perfusion status of the distal extremity and ensures that the treatment is not compromising circulation to the toes.

3. A client with a diagnosis of renal failure is receiving hemodialysis. Which assessment finding should the nurse report to the healthcare provider immediately?

• A. The client's blood pressure is 130/80 mm Hg.
• B. The client gains 1 kg in 24 hours.
• C. The client's potassium level is 5.5 mEq/L.
• D. The client's weight decreases by 0.5 kg in 24 hours.

Correct answer: C

Rationale: A potassium level of 5.5 mEq/L (C) is elevated and concerning in a client with renal failure receiving hemodialysis, as it can lead to life-threatening cardiac arrhythmias. Monitoring blood pressure (A), weight gain (B), and weight loss (D) are essential in clients on hemodialysis, but an elevated potassium level poses an immediate risk that requires prompt intervention.

4. The client is being instructed on the proper use of a metered-dose inhaler. Which instruction should be provided to ensure the optimal benefits from the drug?

• A. Fill your lungs with air through your mouth and then compress the inhaler.
• B. Compress the inhaler while slowly breathing in through your mouth.
• C. Compress the inhaler while inhaling quickly through your nose.
• D. Exhale completely after compressing the inhaler and then inhale.

Correct answer: B

Rationale: The correct technique for using a metered-dose inhaler involves compressing the inhaler while slowly breathing in through the mouth. This method helps ensure that the medication reaches deep into the lungs, allowing for optimal bronchodilation effect. Inhaling quickly through the nose or filling the lungs with air before compressing the inhaler are not recommended techniques for using a metered-dose inhaler effectively.

5. A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement?

• A. Document the client’s temperature fluctuations
• B. Assess for flushed, warm skin consistently
• C. Measure temperature at regular intervals
• D. Use different sites for temperature measurement

Correct answer: C

Rationale: To assess fever patterns accurately, the nurse should measure the client’s temperature at regular intervals. This approach helps in identifying the pattern of fever spikes and fluctuations, which can provide valuable information for diagnostic and treatment purposes. Assessing for flushed, warm skin or documenting circadian rhythms may not directly reveal the fever pattern, while varying temperature measurement sites could lead to inconsistent readings. Therefore, measuring temperature at regular intervals is the most appropriate intervention to identify fever patterns in this scenario.

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