Nursing Elites

1. After undergoing a renal biopsy, a client reports pain radiating to the front of the abdomen from the biopsy site. What finding should the nurse assess the client for?

• A. Bleeding
• B. Renal colic
• C. Infection at the site
• D. Increased temperature

Correct answer: A

Rationale: The correct answer is A: Bleeding. Pain radiating to the front of the abdomen from the renal biopsy site suggests bleeding, which should be promptly assessed and managed. Bleeding can lead to serious complications if not addressed timely. Renal colic (choice B) is associated with kidney stones and typically presents with severe flank pain. Infection at the site (choice C) would more likely present with localized signs such as redness, swelling, warmth, and tenderness. Increased temperature (choice D) alone is not specific to the issue described and may be indicative of various conditions.

2. Polyethylene glycol–electrolyte solution (GoLYTELY) is prescribed for a hospitalized client scheduled for a colonoscopy. The client begins to experience diarrhea after drinking the solution. Which action by the nurse is appropriate?

• A. Calling the physician
• B. Administering a cleansing enema
• C. Documenting the diarrhea in the medical record
• D. Giving intravenous replacement fluids in large amounts

Correct answer: C

Rationale: The correct action by the nurse in this situation is to document the diarrhea in the medical record. Polyethylene glycol–electrolyte solution (GoLYTELY) is a bowel evacuant used to cleanse the bowel before a colonoscopy. It is expected to cause mild diarrhea, which is a normal response to the medication. The diarrhea helps clear the bowel in preparation for the procedure. Calling the physician is not necessary unless there are complications. Administering a cleansing enema or giving intravenous replacement fluids in large amounts are not appropriate actions as they are not indicated for managing the expected diarrhea caused by GoLYTELY.

3. A client has been taking oral corticosteroids for the past five days because of seasonal allergies. Which assessment finding is of most concern to the nurse?

• A. White blood count of 10,000/mm³.
• B. Serum glucose of 115 mg/dL.
• C. Purulent sputum.
• D. Excessive hunger.

Correct answer: C

Rationale: The correct answer is C: Purulent sputum. Corticosteroids can suppress the immune system, increasing the risk of infections. Purulent sputum suggests a possible respiratory infection, which can rapidly progress and lead to complications, making it the most concerning finding. Choice A, a white blood count of 10,000/mm³, is within the normal range and not typically a cause for immediate concern. Choice B, a serum glucose level of 115 mg/dL, is also normal and not directly related to corticosteroid use. Choice D, excessive hunger, is a common side effect of corticosteroids but is not as concerning as a sign of infection indicated by purulent sputum.

4. Which of the following is a sign of hypocalcemia?

• A. Hyperactive reflexes.
• B. Depressed reflexes.
• C. Muscle cramps.
• D. Seizures.

Correct answer: A

Rationale: Hyperactive reflexes are a classic sign of hypocalcemia. Hypocalcemia leads to increased neuromuscular excitability, resulting in hyperactive reflexes. Depressed reflexes (Choice B) are not typically associated with hypocalcemia. Muscle cramps (Choice C) can be seen in hypocalcemia due to muscle irritability but are not a specific sign. Seizures (Choice D) can occur in severe cases of hypocalcemia but are not as common as hyperactive reflexes.

5. Which of the following is a characteristic symptom of multiple sclerosis (MS)?

• A. Muscle atrophy.
• B. Severe pain.
• C. Vision problems.
• D. Hearing loss.

Correct answer: C

Rationale: Vision problems are a characteristic symptom of multiple sclerosis (MS) due to demyelination of the optic nerve. This can lead to issues such as optic neuritis, blurred vision, double vision, or even total vision loss. Muscle atrophy (Choice A) is not a primary symptom of MS but can occur as a secondary effect of decreased mobility. Severe pain (Choice B) is not a typical symptom of MS, though some individuals may experience pain related to muscle spasms or other factors. Hearing loss (Choice D) is not commonly associated with MS unless there is an unrelated concurrent condition affecting the auditory system.

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