Nursing Elites

1. A client who had an abdominal hysterectomy is experiencing minimal urine output despite adequate fluid intake. What should the nurse assess first?

• A. The client's bladder for distension.
• B. The IV catheter insertion site.
• C. The patency of the urinary catheter.
• D. The client's vital signs.

Correct answer: C

Rationale: Assessing the patency of the urinary catheter is crucial in this situation. A blocked catheter could be a common cause of decreased urine output following surgery. While checking the IV catheter insertion site (Choice B) is important, it is not the priority in this case. Examining the client's bladder for distension (Choice A) is relevant, but assessing the patency of the catheter takes precedence in resolving the issue of decreased urine output. Monitoring vital signs (Choice D) is a routine nursing task but not the priority when dealing with decreased urine output post-surgery.

2. Inspiratory and expiratory stridor may be heard in a client who:

• A. Is experiencing an exacerbation of goiter
• B. Is experiencing an acute asthmatic attack
• C. Has aspirated a piece of meat
• D. Has severe laryngotracheitis

Correct answer: D

Rationale: Inspiratory and expiratory stridor are high-pitched, wheezing sounds caused by disrupted airflow due to airway obstruction. Severe laryngotracheitis, involving inflammation and swelling of the larynx and trachea, leads to airway obstruction and can produce both inspiratory and expiratory stridor. Exacerbation of goiter, an acute asthmatic attack, and aspiration of a piece of meat are not typically associated with both inspiratory and expiratory stridor. Therefore, choices A, B, and C are incorrect.

3. What is the most common genetic cause of intellectual disability?

• A. Down syndrome
• B. Fragile X syndrome
• C. Prader-Willi syndrome
• D. Turner syndrome

Correct answer: B

Rationale: The correct answer is Fragile X syndrome because it is the most common inherited cause of intellectual disability, resulting from a mutation in the FMR1 gene. Down syndrome, Prader-Willi syndrome, and Turner syndrome are not the most common genetic causes of intellectual disability. Down syndrome is caused by the presence of an extra chromosome 21, Prader-Willi syndrome results from specific genetic abnormalities on chromosome 15, and Turner syndrome is characterized by the absence of part or all of one of the X chromosomes.

4. An adult client is undergoing weekly external radiation treatments for breast cancer. Upon arrival at the outpatient clinic for a scheduled treatment, the client reports increasing fatigue to the nurse who is taking the client's vital signs. What action should the nurse implement?

• A. Notify the healthcare provider or charge nurse immediately
• B. Offer to reschedule the treatment for the following week
• C. Plan to monitor the client's vital signs every 30 minutes
• D. Reinforce the need for extra rest periods and plenty of sleep

Correct answer: D

Rationale: Fatigue is a common side effect of radiation therapy. In this scenario, the appropriate action for the nurse to take is to reinforce the importance of rest and adequate sleep. It is crucial to address the client's increasing fatigue by promoting self-care strategies such as additional rest periods and ensuring plenty of sleep. Rescheduling the treatment is not necessary for fatigue, and vital sign monitoring every 30 minutes may not directly address the client's reported symptom. Notifying the healthcare provider or charge nurse immediately is not the first-line intervention for increasing fatigue, as this symptom can be managed through education and self-care recommendations.

5. The home health PN suspects elder abuse after observing fresh lacerations on the arms and legs of an older adult male client who lives with his daughter. Which action is most important for the PN to take?

• A. Document the lacerations in the client's record
• B. Report findings to the supervisor for referral to adult protective services
• C. Ask the daughter who has been taking care of the client on a daily basis
• D. Apply dry dressings after cleansing the wounds

Correct answer: B

Rationale: The most important action for the PN to take in this situation is to report the findings to the supervisor for referral to adult protective services. Suspected elder abuse must be reported promptly to ensure the safety and protection of the client. Documenting the lacerations in the client's record is important but not as critical as reporting the suspected abuse. Asking the daughter who is the potential abuser may not yield accurate information and could compromise the safety of the client. Applying dressings to the wounds is a lower priority compared to addressing the suspected elder abuse.

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