Nursing Elites

1. What action will the nurse plan to take for a 40-year-old patient with multiple sclerosis (MS) who has urinary retention caused by a flaccid bladder?

• A. Decrease the patient's evening fluid intake.
• B. Teach the patient how to use the Cred method.
• C. Suggest the use of adult incontinence briefs for nighttime only.
• D. Assist the patient to the commode every 2 hours during the day.

Correct answer: B

Rationale: For a 40-year-old patient with multiple sclerosis experiencing urinary retention due to a flaccid bladder, teaching the Cred method is the appropriate action. The Cred method involves applying manual pressure over the bladder to aid in bladder emptying. Decreasing fluid intake is not the correct approach as it will not address the underlying issue of bladder emptying and may lead to dehydration and urinary tract infections. Using adult incontinence briefs only addresses the symptom of incontinence without addressing the bladder emptying problem. Assisting the patient to the commode every 2 hours does not actively address the issue of improving bladder emptying as effectively as teaching the Cred method.

2. A patient is admitted and complains of gastric pain, fever, and diarrhea. Which assessment finding should be reported to the healthcare provider immediately?

• A. Abdominal distention
• B. A bruit near the epigastric area
• C. 3 episodes of vomiting in the last hour
• D. Blood pressure of 160/90

Correct answer: B

Rationale: A bruit near the epigastric area may indicate the presence of an aortic aneurysm, which is a life-threatening condition requiring immediate medical attention. Abdominal distention, while concerning, may not be as urgent as a potential aneurysm. Vomiting episodes may suggest underlying issues but do not present an immediate life-threatening situation. A blood pressure of 160/90, though elevated, does not pose the same level of immediate threat as a potential aortic aneurysm.

3. Rhogam is most often used to treat____ mothers that have a ____ infant.

• A. RH positive, RH positive
• B. RH positive, RH negative
• C. RH negative, RH positive
• D. RH negative, RH negative

Correct answer: C

Rationale: Rhogam is administered to RH-negative mothers who have an RH-positive infant to prevent the development of anti-RH antibodies in the mother's system. Choice A (RH positive, RH positive) is incorrect because Rhogam is not used when both mother and infant are RH positive. Choice B (RH positive, RH negative) is incorrect because Rhogam is used when the mother is RH negative, not RH positive. Choice D (RH negative, RH negative) is incorrect as Rhogam is not typically needed if both mother and infant are RH negative.

4. A victim of domestic violence states, 'If I were better, I would not have been beaten.' Which feeling best describes what the victim may be experiencing?

• A. Fear
• B. Helplessness
• C. Self-blame
• D. Rejection

Correct answer: C

Rationale: The correct answer is self-blame. In this scenario, the victim is attributing the abuse to their own inadequacies or faults, thinking that if they were different, the abuse would not occur. This is a common response seen in victims of domestic violence, where they wrongly internalize the blame for the abuser's actions. Fear (Choice A) is a valid emotion, but in this case, the victim is not expressing fear but rather self-blame. Helplessness (Choice B) is also a common feeling in victims of domestic violence, but in this specific statement, the victim is demonstrating self-blame. Rejection (Choice D) does not accurately reflect the victim's statement and emotional response in the given scenario.

5. After an endoscopic procedure with general anesthesia, what is a priority nursing consideration for a patient in the day surgery center?

• A. Raise the siderails of the patient's bed
• B. Do not offer fluids, food, or any oral intake
• C. Check the temperature of the patient
• D. Teach the patient to avoid aspirin or NSAIDS

Correct answer: B

Rationale: After an endoscopic procedure with general anesthesia, the priority nursing consideration is to not offer fluids, food, or any oral intake to the patient. Endoscopies involve passing a tube through the mouth into the esophagus or upper GI. Anesthesia is often given to inactivate the gag reflex, making the patient vulnerable to aspiration. Raising the siderails of the patient's bed is important for safety but not the immediate priority. Checking the patient's temperature may be important but is not the priority immediately after the procedure. Teaching the patient to avoid aspirin or NSAIDS is important for post-procedure care but is not the priority immediately after the endoscopic procedure.

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