Nursing Elites

1. The nurse is caring for a client diagnosed with rule-out nephritic syndrome. Which intervention should be included in the plan of care?

• A. Monitor the urine for bright-red bleeding
• B. Evaluate the calorie count of the 500-mg protein diet
• C. Assess the client’s sacrum for dependent edema
• D. Monitor for a high serum albumin level

Correct answer: C

Rationale: The correct intervention to include in the plan of care for a client with rule-out nephritic syndrome is to assess the client’s sacrum for dependent edema. Dependent edema is common in nephritic syndrome due to protein loss, and monitoring for this helps manage the condition. Choices A, B, and D are incorrect. Monitoring the urine for bright-red bleeding may be more relevant for a client with a different condition, such as glomerulonephritis. Evaluating the calorie count of a 500-mg protein diet is not directly related to managing nephritic syndrome. Monitoring for a high serum albumin level does not directly address the symptom of dependent edema associated with nephritic syndrome.

2. The nurse in the pediatric clinic performs a physical assessment of a 13-year-old boy. Which of the following findings by the nurse requires an immediate intervention?

• A. The adolescent complains of his scrotum aching after exercise. The nurse palpates a worm-like mass above the testes
• B. The nurse noted unilateral breast enlargement
• C. The child’s scrotum appears swollen, and a soft mass is palpated. The nurse is unable to insert a finger above the mass
• D. The child’s scrotum appears enlarged and red. The nurse palpated a thickened and swollen spermatic cord.

Correct answer: D

Rationale: A swollen and thickened spermatic cord could indicate testicular torsion, which is a surgical emergency.

3. For a patient on lithium therapy, which dietary recommendation is essential?

• A. Increase caffeine intake
• B. Increase sodium intake
• C. Increase protein intake
• D. Increase fiber intake

Correct answer: B

Rationale: The correct answer is to increase sodium intake. For patients on lithium therapy, maintaining consistent sodium intake is crucial to avoid fluctuations in drug levels. Increasing caffeine intake (choice A) is not recommended as it can interfere with lithium levels. While protein intake (choice C) is important for overall health, it is not specifically essential for patients on lithium therapy. Similarly, increasing fiber intake (choice D) is beneficial but not a primary concern for patients on lithium therapy.

4. The best position for any procedure that involves vaginal and cervical examination is

• A. Dorsal recumbent
• B. Side lying
• C. Supine
• D. Lithotomy

Correct answer: D

Rationale: The lithotomy position is the most suitable position for procedures involving vaginal and cervical examination because it provides the best access to the vaginal and cervical regions. In this position, the patient lies on their back with their legs flexed and feet placed in stirrups, allowing for optimal visualization and access to the area. This position facilitates proper examination, diagnosis, and treatment when working in the gynecological field. The other options (dorsal recumbent, side lying, and supine) do not provide the same level of access and visualization as the lithotomy position, making them less ideal for vaginal and cervical examinations.

5. A client is prescribed lisinopril (Zestril) for the treatment of hypertension. He asks the nurse about possible adverse effects. The nurse should inform him about which common adverse effects of angiotensin-converting enzyme (ACE) inhibitors?

• A. Constipation
• B. Dizziness
• C. Headache
• D. B, C

Correct answer: D

Rationale: The correct answer is D: 'Dizziness' and 'Headache'. ACE inhibitors like lisinopril are known to cause these common side effects due to their blood pressure-lowering effects. Choice A, 'Constipation', is not a common adverse effect associated with ACE inhibitors. While constipation can be a side effect of some medications, it is not typically seen with ACE inhibitors. Therefore, options A and B are incorrect choices.

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