Nursing Elites

1. A nurse is receiving a report on four clients. Which of the following clients should the nurse assess first?

• A. A client who has an ileal conduit and mucus in the pouch
• B. Client with arteriovenous fistula with additional vibration palpated
• C. A client with chronic kidney disease and cloudy dialysate outflow
• D. A client with transurethral resection of the prostate with red-tinged urine

Correct answer: C

Rationale: The nurse should assess the client with chronic kidney disease and cloudy dialysate outflow first because cloudy dialysate outflow suggests peritonitis, a serious complication of peritoneal dialysis that requires immediate intervention. Assessing and addressing peritonitis promptly is crucial to prevent further complications and ensure the client's safety. Choices A, B, and D present important findings that require attention but are not as urgent as peritonitis, which can quickly escalate and endanger the client's health.

2. A healthcare professional is planning a community education program about colorectal cancer. Which of the following risk factors should the professional identify as modifiable?

• A. Family history
• B. Smoking
• C. Age
• D. Gender

Correct answer: B

Rationale: The correct answer is B: Smoking. Smoking is a modifiable risk factor for colorectal cancer. It is within an individual's control to quit smoking, thereby reducing their risk of developing colorectal cancer. Choices A, C, and D are non-modifiable risk factors. Family history, age, and gender are factors that individuals cannot change or control. While family history can influence risk, it is not something that can be modified. Age and gender are also non-modifiable factors when it comes to colorectal cancer risk.

3. A home health nurse is providing teaching to a family of a client who has seizure manifestations as a result of an inoperable brain tumor. What intervention should the nurse include in the teaching?

• A. Administer antiseizure medications promptly.
• B. Use oral airway devices during seizures.
• C. Pad the side rails of the bed.
• D. Apply restraints during the seizure to prevent injury.

Correct answer: C

Rationale: The correct intervention the nurse should include in the teaching is to pad the side rails of the bed. By padding the side rails, the nurse can help prevent injury if the patient experiences a seizure. Administering antiseizure medications promptly (Choice A) is typically the responsibility of a healthcare provider or according to a prescribed schedule. Using oral airway devices during seizures (Choice B) can pose risks and should be managed by healthcare professionals. Applying restraints during a seizure (Choice D) is not recommended as it can lead to further injury and complications.

4. A client with chronic renal failure needs dietary instructions. Which of the following should the nurse provide?

• A. Increase calcium intake
• B. Provide a diet high in potassium
• C. Restrict protein intake
• D. Increase fluid intake

Correct answer: C

Rationale: The correct answer is to instruct the client to restrict protein intake. In chronic renal failure, the kidneys are unable to effectively filter waste products, so limiting protein helps reduce the buildup of waste in the body. Increasing calcium intake (Choice A) is not typically necessary unless there is a specific deficiency. Providing a diet high in potassium (Choice B) is contraindicated as potassium levels need to be monitored and controlled in renal failure. Increasing fluid intake (Choice D) may be necessary depending on the individual's condition, but restricting protein intake is a more critical dietary instruction for clients with chronic renal failure.

5. A client is receiving oxytocin to augment labor. The contractions are occurring every 45 seconds, and the fetal heart rate is 170-180 beats/min. What action should the nurse take?

• A. Increase the oxytocin infusion
• B. Decrease the oxytocin infusion
• C. Discontinue the oxytocin infusion
• D. Maintain the oxytocin infusion

Correct answer: C

Rationale: When contractions occur every 45 seconds with a high fetal heart rate, it indicates uterine hyperstimulation and fetal distress. In this situation, the oxytocin infusion should be discontinued immediately to prevent further complications. Increasing or maintaining the infusion would worsen the hyperstimulation and distress. Decreasing the infusion may not be sufficient to address the current situation and could still lead to complications.

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