Nursing Elites

1. A client diagnosed with cirrhosis of the liver and ascites is receiving Spironolactone (Aldactone). The nurse understands that this medication spares the elimination of which element?

• A. Sodium
• B. Potassium
• C. Phosphate
• D. Albumin

Correct answer: B

Rationale: The correct answer is B: Potassium. Spironolactone is a potassium-sparing diuretic, which means it helps retain potassium while eliminating sodium. This is beneficial for patients with cirrhosis and ascites as they are at risk of low potassium levels. Choice A, Sodium, is incorrect as Spironolactone does not spare the elimination of sodium but rather helps eliminate it. Choice C, Phosphate, is incorrect as Spironolactone does not directly affect phosphate levels. Choice D, Albumin, is incorrect as Spironolactone does not spare the elimination of albumin.

2. While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse's best response?

• A. As you urinate more, you will need less medication to control fluid.
• B. You will have to take this medication for about a year.
• C. The medication must be continued so the fluid problem is controlled.
• D. Please talk to your health care provider about medications and treatments.

Correct answer: C

Rationale: Diuretics must be continued to control fluid retention, as stopping them can lead to worsening of congestive heart failure.

3. The nurse is assessing a client 2 hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse's first action should be to

• A. Wrap the leg with elastic bandages
• B. Apply pressure at the bleeding site
• C. Reinforce the dressing and elevate the leg
• D. Remove the dressings and re-dress the incision

Correct answer: B

Rationale: In this scenario where the upper leg dressing becomes saturated with blood post-femoral popliteal bypass, the nurse's first action should be to apply pressure at the bleeding site. Applying pressure is essential to control hemorrhage and prevent further blood loss. Choice A is incorrect as wrapping the leg with elastic bandages would not address the immediate issue of controlling the bleeding. Choice C is incorrect because reinforcing the dressing and elevating the leg should come after controlling the bleeding. Choice D is incorrect as removing the dressings and re-dressing the incision should only be done after the bleeding is under control to prevent excessive blood loss.

4. A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the health care provider?

• A. Light pink urine
• B. Occasional suprapubic cramping
• C. Minimal drainage into the urinary collection bag
• D. Complaints of the feeling of pulling on the urinary catheter

Correct answer: C

Rationale: In a client with an indwelling catheter and continuous bladder irrigation post TURP, minimal drainage into the urinary collection bag should be reported to the health care provider. This finding could indicate a blockage in the catheter or a complication that requires immediate attention. Light pink urine (choice A) is expected due to bladder irrigation. Occasional suprapubic cramping (choice B) is common post-TURP. Complaints of the feeling of pulling on the urinary catheter (choice D) may indicate discomfort but do not suggest an urgent issue like a potential blockage.

5. A nurse is assessing several clients in a long-term health care facility. Which client is at highest risk for the development of decubitus ulcers?

• A. A 79-year-old malnourished client on bed rest
• B. An obese client who uses a wheelchair
• C. A client who had 3 episodes of incontinent diarrhea
• D. An 80-year-old ambulatory diabetic client

Correct answer: A

Rationale: A malnourished client on bed rest is at the highest risk for developing decubitus ulcers due to a combination of factors such as poor nutritional status and immobility. Malnourished individuals have compromised skin integrity, making them more susceptible to pressure ulcers. Being on bed rest further exacerbates this risk as constant pressure on bony prominences can lead to tissue damage. Although the other choices may also be at risk for developing decubitus ulcers, the malnourished client on bed rest presents the highest risk due to the combination of malnutrition and immobility.

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