Nursing Elites

1. A 60-year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him void?

• A. Have him drink several glasses of water
• B. Crede the bladder from the bottom to the top
• C. Assist him to stand by the side of the bed to void
• D. Wait 2 hours and have him try to void again

Correct answer: C

Rationale: Assisting the client to stand by the side of the bed to void is the most appropriate action. This position can help stimulate voiding due to gravity and normal positioning. Having the client drink water (Choice A) may help, but assisting him to stand is more effective. Crede maneuver (Choice B) is not recommended as it can increase the risk of bladder trauma. Waiting for 2 hours (Choice D) without taking any action is not proactive in addressing the client's inability to void.

2. A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the staff members that the most significant routine infection control strategy, in addition to hand washing, to be implemented is which of these?

• A. Apply appropriate signs outside and inside the room
• B. Apply a mask with a shield if there is a risk of fluid splash
• C. Wear a gown to change soiled linens from incontinence
• D. Have gloves on while handling bedpans with feces

Correct answer: D

Rationale: The correct answer is to have gloves on while handling bedpans with feces. Hepatitis A is transmitted through the fecal-oral route, and using gloves during such direct contact with feces is crucial in preventing the transmission of the infection. Choice A is not directly related to infection control for hepatitis A. Choice B is more relevant to preventing droplet transmission rather than fecal-oral transmission. Choice C is important for preventing contact transmission from soiled linens but is not as directly related to the mode of transmission of hepatitis A as using gloves when handling feces.

3. A middle-aged woman talks to the nurse in the healthcare provider's office about uterine fibroids, also called leiomyomas or myomas. What statement by the woman indicates more education is needed?

• A. I am one of every 4 women that get fibroids, and among women my age - between the 30s or 40s, fibroids occur more frequently.
• B. My fibroids are noncancerous tumors that grow slowly.
• C. The associated problems I have had are pelvic pressure and pain, urinary incontinence, frequent urination, urine retention, and constipation.
• D. Fibroids that cause no problems still need to be taken out.

Correct answer: D

Rationale: The correct answer is D because fibroids that are asymptomatic usually do not require treatment or removal. The statement 'Fibroids that cause no problems still need to be taken out' indicates a need for further education. Choice A correctly states the frequency of fibroids in women and their age group. Choice B accurately describes fibroids as noncancerous slow-growing tumors. Choice C lists common symptoms associated with uterine fibroids.

4. When a client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer, which of the following should take priority in planning care?

• A. Esophagitis
• B. Leukopenia
• C. Fatigue
• D. Skin irritation

Correct answer: B

Rationale: Leukopenia should take priority in planning care for a client receiving external beam radiation to the mediastinum for bronchial cancer because it is a serious side effect that increases the risk of infection. Monitoring leukopenia is crucial to prevent complications. Esophagitis, fatigue, and skin irritation are also potential side effects of radiation therapy, but leukopenia poses a higher risk of life-threatening infections, requiring immediate attention.

5. For a client with chronic kidney disease having a hemoglobin level of 8.0 g/dL, which intervention should the nurse perform first?

• A. Administer erythropoietin as ordered
• B. Monitor the client's blood pressure
• C. Monitor the client's oxygen saturation level
• D. Assess the client for signs of fatigue

Correct answer: A

Rationale: Administering erythropoietin is the priority intervention for a client with chronic kidney disease and a low hemoglobin level. Erythropoietin stimulates red blood cell production, helping to manage anemia in these clients. Monitoring blood pressure, oxygen saturation level, and assessing for signs of fatigue are important aspects of care but addressing the anemia by administering erythropoietin takes precedence to improve oxygen-carrying capacity and overall well-being.

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