Nursing Elites

1. Which of the following is not an indication for pelvic ultrasonography?

• A. to measure uterine size
• B. to detect multiple pregnancies
• C. to measure renal size
• D. to detect foreign bodies

Correct answer: C

Rationale: Pelvic ultrasonography is commonly used to assess various conditions. Choices A, B, and D are all valid reasons for performing pelvic ultrasonography. Measuring uterine size helps evaluate conditions like fibroids, while detecting multiple pregnancies is essential for prenatal care. Furthermore, identifying foreign bodies can aid in diagnosing certain conditions. However, assessing renal size is typically not a primary reason for pelvic ultrasonography, making choice C the correct answer.

2. A nurse is preparing for the admission of a client with pulmonary tuberculosis. Which action reflects the use of evidence-based practice in the care of the client?

• A. Keeping the door to the client's room closed
• B. Fitting the client for an N95 or HEPA (high-efficiency particulate air) mask to be worn at all times
• C. Placing the client in a semiprivate room with a cohort client
• D. Using a surgical mask when entering the client's room

Correct answer: A

Rationale: Evidence-based practice is an approach to client care that integrates the client's preferences, clinical expertise, and the best research evidence to deliver quality care. In the case of pulmonary tuberculosis, which is transmitted through the airborne route, keeping the door to the client's room closed is crucial to prevent the spread of infection. Placing the client in a semiprivate room with a cohort client is not recommended for airborne precautions; a private room is required to prevent transmission. Fitting the client for an N95 or HEPA mask is essential for the nurse's protection when entering the room, not for the client to wear at all times. Using a surgical mask when entering the client's room is not sufficient for airborne precautions; an N95 or HEPA mask is necessary.

3. A nurse is planning client assignments for the day. Which task should the nurse assign to the nursing assistant (unlicensed assistive personnel)?

• A. Recording the urinary output for a client with renal calculi whose urine must be strained
• B. Dressing change instructions for a client who had a mastectomy 2 days ago
• C. Reporting abnormal lab values to the health care provider for a client scheduled for a laparoscopic cholecystectomy
• D. Preprocedural teaching for a client scheduled for a cardiac stress test

Correct answer: A

Rationale: The nurse is legally responsible for client assignments and must assign tasks based on state nursing practice act guidelines and job descriptions provided by the employing agency. The nursing assistant is trained to measure, collect, and strain urine, making recording urinary output for a client with renal calculi a suitable task for the nursing assistant. This task falls within the nursing assistant's role description. Dressing change instructions for a client who had a mastectomy involve a higher level of skill and knowledge, beyond the scope of a nursing assistant. Reporting abnormal lab values to the health care provider for a client scheduled for a laparoscopic cholecystectomy requires interpretation and clinical judgment, which is typically not within the nursing assistant's role. Preprocedural teaching for a client scheduled for a cardiac stress test involves providing detailed information and education, which is usually the responsibility of a licensed nurse or other qualified healthcare provider.

4. Which sign might a healthcare professional observe in a client with a high ammonia level?

• A. coma
• B. edema
• C. hypoxia
• D. polyuria

Correct answer: A

Rationale: A high ammonia level can lead to hepatic encephalopathy, which includes symptoms like confusion, disorientation, and can progress to coma. Coma is a severe condition of unconsciousness. Edema is swelling caused by excess fluid trapped in body tissues, not typically associated with high ammonia levels. Hypoxia is a condition of inadequate oxygen supply to tissues and organs, not directly related to high ammonia levels. Polyuria is excessive urination, which is not a typical sign of high ammonia levels.

5. When a client needs oxygen therapy, what is the highest flow rate that oxygen can be delivered via nasal cannula?

• A. 2 liters/minute
• B. 4 liters/minute
• C. 6 liters/minute
• D. 8 liters/minute

Correct answer: C

Rationale: The correct answer is 6 liters/minute. When a client requires oxygen therapy, the maximum flow rate that oxygen can be delivered via nasal cannula is 6 liters/minute. Nasal cannula can effectively deliver oxygen up to 6 liters/minute. Flow rates exceeding 6 liters/minute may lead to drying of the nasal passages and discomfort for the client. Higher flow rates, like 8 liters/minute, should be administered using a mask to ensure sufficient oxygenation. Options A, B, and D are incorrect as they indicate flow rates that surpass the recommended maximum for nasal cannula delivery.

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