Nursing Elites

1. What is the best way to assess a patient's respiratory function after surgery?

• A. Check oxygen saturation
• B. Auscultate lung sounds
• C. Check for abnormal breath sounds
• D. Check skin color

Correct answer: A

Rationale: The correct answer is to check oxygen saturation. This is because checking oxygen saturation provides a direct measure of how well the patient is oxygenating post-surgery. It helps healthcare providers assess if the patient is receiving enough oxygen to meet their body's needs. Auscultating lung sounds (choice B) is important to assess respiratory function but may not provide an immediate indication of oxygenation status. Checking for abnormal breath sounds (choice C) is relevant but does not directly assess oxygenation levels. Checking skin color (choice D) can provide some information about oxygenation, but it is not as precise or direct as measuring oxygen saturation.

2. A healthcare professional is reviewing the medical record of a client scheduled for a CT scan with contrast media. The healthcare professional should identify which of the following findings as a contraindication to the procedure?

• A. White blood cell count of 6,000/mm³
• B. Urine specific gravity of 1.025
• C. History of asthma
• D. History of allergy to shellfish

Correct answer: D

Rationale: The correct answer is D, a history of allergy to shellfish. A known allergy to shellfish is a contraindication for the use of contrast media in a CT scan due to the potential risk of an allergic reaction, which could be severe and life-threatening. Choices A, B, and C are not contraindications to the procedure. A normal white blood cell count, urine specific gravity within the normal range, and a history of asthma do not typically interfere with the administration of contrast media for a CT scan.

3. How should fluid balance be assessed in a patient receiving diuretics?

• A. Monitor daily weight
• B. Monitor intake and output
• C. Check for edema
• D. Monitor blood pressure

Correct answer: A

Rationale: Corrected Rationale: Monitoring daily weight is the most accurate method to assess fluid balance in patients receiving diuretics. Changes in weight reflect changes in fluid balance, making it a sensitive indicator. Monitoring intake and output (choice B) is important but may not provide a complete picture of overall fluid balance. Checking for edema (choice C) is a late sign of fluid imbalance and may not be sensitive enough to detect subtle changes. Monitoring blood pressure (choice D) is relevant but may not directly reflect fluid balance as it can be influenced by various other factors.

4. A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 ml/hr. What intervention should the nurse anticipate?

• A. Clamp the catheter.
• B. Administer a fluid bolus.
• C. Obtain a urine specimen for culture and sensitivity.
• D. Initiate continuous bladder irrigation.

Correct answer: D

Rationale: In this scenario, the nurse should anticipate initiating continuous bladder irrigation. Dark yellow urine output at a rate of 25 ml/hr following abdominal surgery may indicate urinary stasis or obstruction, which could lead to complications like urinary retention. Continuous bladder irrigation helps prevent catheter obstruction and manage urinary retention by ensuring patency and promoting urine flow. Clamping the catheter (Choice A) could lead to urinary stasis and should be avoided. Administering a fluid bolus (Choice B) is not indicated solely based on the urine color and output described. Obtaining a urine specimen for culture and sensitivity (Choice C) may be necessary for assessing infection but does not directly address the issue of urinary stasis or obstruction.

5. A client with gastroesophageal reflux disease (GERD) is being taught about lifestyle modifications. Which of the following instructions should be included?

• A. Sleep with the head of the bed elevated.
• B. Avoid drinking fluids with meals.
• C. Eat three large meals each day.
• D. Lie down after eating.

Correct answer: B

Rationale: The correct instruction for a client with GERD is to avoid drinking fluids with meals. This is because consuming fluids while eating can exacerbate reflux symptoms by increasing stomach distension and contributing to the reflux of stomach contents into the esophagus. Option A is incorrect as elevating the head of the bed can help prevent reflux during sleep, not while drinking fluids. Option C is incorrect as consuming three large meals a day can worsen GERD symptoms due to increased gastric distension. Option D is incorrect as lying down after eating can also worsen GERD symptoms by promoting the reflux of stomach contents into the esophagus.

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