Nursing Elites

1. A client with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse include in the client's postoperative discharge instructions?

• A. Report when hematuria becomes pink-tinged
• B. Use incentive spirometer
• C. Restrict physical activities
• D. Monitor urinary stream for a decrease in output

Correct answer: D

Rationale: After lithotripsy, monitoring the urinary stream for a decrease in output is essential to identify any potential complications such as urinary retention or obstruction. Reporting pink-tinged hematuria is important, but monitoring the urinary stream for a decrease in output takes precedence as it directly assesses renal function and potential complications. Using an incentive spirometer is not directly related to post-lithotripsy care. Restricting physical activities may be necessary initially but is not the priority compared to monitoring urinary output.

2. A client with asthma is prescribed a metered-dose inhaler (MDI) with albuterol. Which instruction is essential for the nurse to provide?

• A. Use the inhaler only before bedtime
• B. Shake the inhaler well before use
• C. Exhale fully before inhaling the medication
• D. Take two puffs every hour

Correct answer: B

Rationale: The correct answer is to 'Shake the inhaler well before use.' This instruction is crucial as shaking the inhaler ensures the proper mixing of the medication, which is essential for its effective delivery. Option A is incorrect because using the inhaler only before bedtime may not provide adequate relief during the day. Option C is incorrect as exhaling fully is a good practice but not the most essential instruction. Option D is incorrect as taking two puffs every hour may exceed the recommended dosage and lead to adverse effects.

3. The nurse is teaching a client about coronary artery disease (CAD) preventive health. Which behavior stated by the client indicates a need for additional information and teaching?

• A. Increasing physical activity.
• B. Eating a low-fat diet.
• C. Decreasing the number of cigarettes smoked per day.
• D. Monitoring blood pressure regularly.

Correct answer: C

Rationale: The correct answer is C. Decreasing the number of cigarettes smoked per day is not sufficient for CAD prevention. Smoking cessation is crucial in reducing the risk of CAD. While increasing physical activity, eating a low-fat diet, and monitoring blood pressure regularly are all positive behaviors for CAD prevention, quitting smoking should be emphasized due to its significant impact on cardiovascular health.

4. An unlicensed assistive personnel (UAP) reports to the nurse that a client with a postoperative wound infection has a temperature of 103.8°F, blood pressure 90/70, pulse 124 beats/min, and respirations of 28 breaths/min. When the nurse assesses the client's findings, they include a mottled skin appearance and confusion. Which action should the nurse take first?

• A. Obtain a wound specimen for culture.
• B. Initiate an infusion of intravenous (IV) fluids.
• C. Transfer the client to the ICU.
• D. Assess the client's core temperature.

Correct answer: B

Rationale: The correct action for the nurse to take first is to initiate an infusion of intravenous (IV) fluids. In this scenario, the client is showing signs of sepsis, indicated by a high temperature, low blood pressure, rapid heart rate, and increased respiratory rate. Mottled skin appearance and confusion are also signs of poor perfusion. Initiating IV fluids is crucial in treating sepsis to maintain blood pressure and perfusion. Obtaining a wound specimen for culture (Choice A) can be important but is not the priority at this moment. Transferring the client to the ICU (Choice C) can be considered after stabilizing the client. Assessing the client's core temperature (Choice D) is not the immediate priority compared to addressing the signs of sepsis and poor perfusion.

5. The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding?

• A. Nuchal rigidity
• B. Carotid bruit
• C. Jugular vein distention
• D. Palpable cervical lymph node

Correct answer: B

Rationale: The correct answer is B: Carotid bruit. A carotid bruit is a significant risk factor for stroke as it indicates turbulent blood flow due to narrowing of the carotid artery. Nuchal rigidity is associated with meningitis, jugular vein distention can be a sign of heart failure, and palpable cervical lymph nodes may indicate infection, but they are not directly linked to stroke risk.

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