Nursing Elites

1. A nurse is assessing a client who has Guillain-Barré syndrome. Which of the following findings should the nurse expect?

• A. Increased urine output.
• B. Hyperactive reflexes.
• C. Hypoactive bowel sounds.
• D. Facial weakness.

Correct answer: D

Rationale: Facial weakness is a common finding in clients with Guillain-Barré syndrome due to muscle weakness. While increased urine output is not typically associated with Guillain-Barré syndrome, hyperactive reflexes are more indicative of conditions like hyperthyroidism or spinal cord injury. Hypoactive bowel sounds are not a classic finding in Guillain-Barré syndrome, making it an incorrect choice.

2. A client is being taught how to perform self-catheterization. Which of the following instructions should the nurse include?

• A. Clean the catheter with alcohol after each use.
• B. Perform self-catheterization while sitting on the toilet.
• C. Use a new catheter each time you perform self-catheterization.
• D. Lubricate the catheter tip with petroleum jelly before insertion.

Correct answer: C

Rationale: The correct answer is C: 'Use a new catheter each time you perform self-catheterization.' It is essential to use a new, sterile catheter each time to prevent infection during the procedure. Choice A is incorrect because cleaning the catheter with alcohol may not be sufficient to prevent infection. Choice B is incorrect because self-catheterization is typically done in a clean, private area, not necessarily on the toilet. Choice D is incorrect because lubricating the catheter tip with petroleum jelly is a common practice but not as crucial as using a new catheter each time to prevent infection.

3. A healthcare provider is providing dietary teaching to a client who has osteoporosis. Which of the following foods should the healthcare provider recommend as the best source of calcium?

• A. Broccoli
• B. Cheddar cheese
• C. Almonds
• D. Fortified orange juice

Correct answer: B

Rationale: Cheddar cheese is a rich source of calcium and should be recommended to clients with osteoporosis. While broccoli and almonds also contain calcium, cheddar cheese provides a higher amount per serving. Fortified orange juice may contain added calcium, but it is not as concentrated a source as cheddar cheese. Therefore, the best choice for a client with osteoporosis seeking a high calcium food is cheddar cheese.

4. A nurse is providing teaching to a client who has a new prescription for digoxin. Which of the following instructions should the nurse include?

• A. Avoid taking this medication with antacids.
• B. Contact your provider if you experience visual changes.
• C. Increase your intake of foods high in potassium.
• D. You may experience increased urination while taking this medication.

Correct answer: B

Rationale: The correct answer is B: 'Contact your provider if you experience visual changes.' Visual changes, such as blurred or yellow vision, can indicate digoxin toxicity and should be reported immediately to the healthcare provider for further evaluation and management. Choice A is incorrect because digoxin can be taken with antacids. Choice C is incorrect because increasing potassium intake can lead to hyperkalemia when taking digoxin. Choice D is incorrect because increased urination is not a common side effect of digoxin.

5. A nurse overhears two assistive personnel (AP) discussing care for a client in the elevator. What action should the nurse take?

• A. Contact the client's family about the incident.
• B. Notify the client's provider about the incident.
• C. File a complaint with the ethics committee.
• D. Report the incident to the AP's charge nurse.

Correct answer: D

Rationale: The correct action for the nurse to take in this situation is to report the incident to the AP's charge nurse. This ensures that the issue is addressed internally and allows for proper handling of the situation. Contacting the client's family about the incident (Choice A) may not be appropriate as it could breach confidentiality and escalate the situation unnecessarily. Notifying the client's provider (Choice B) is not the most immediate and effective step to address the issue. Filing a complaint with the ethics committee (Choice C) should be reserved for serious ethical violations, and in this case, reporting to the charge nurse is the more practical and immediate course of action.

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