Nursing Elites

1. A nurse is caring for a client who is having difficulty voiding following the removal of an indwelling urinary catheter. Which of the following interventions should the nurse take?

• A. Assess for bladder distention after 6 hours
• B. Encourage the client to use a bedpan in the supine position
• C. Restrict the client's intake of oral fluids
• D. Pour warm water over the client's perineum

Correct answer: D

Rationale: The correct answer is to pour warm water over the client's perineum. This intervention can help stimulate voiding after catheter removal by promoting relaxation of the perineal muscles and increasing sensory input to the bladder. Assessing for bladder distention after 6 hours (Choice A) is important but not the initial intervention for difficulty voiding. Encouraging the client to use a bedpan in the supine position (Choice B) may not be effective in promoting voiding. Restricting the client's intake of oral fluids (Choice C) is not appropriate as hydration is important for urinary function.

2. A nurse is caring for a client who is in the early stages of hypovolemic shock. Which of the following findings should the nurse expect?

• A. Heart rate 60/min
• B. Increased urinary output
• C. Increased respiratory rate
• D. Hypothermia

Correct answer: C

Rationale: In the early stages of hypovolemic shock, the body initiates compensatory mechanisms to maintain perfusion. One of these mechanisms is an increased respiratory rate to improve oxygen delivery. This helps to offset the decreased circulating blood volume. A heart rate of 60/min (choice A) is not expected in hypovolemic shock; instead, tachycardia is a common finding due to the body's attempt to maintain cardiac output. Increased urinary output (choice B) is not typically seen in hypovolemic shock as the body tries to conserve fluid. Hypothermia (choice D) is usually a late sign of shock when the body's compensatory mechanisms are failing, and perfusion is severely compromised.

3. How can a healthcare provider prevent deep vein thrombosis (DVT) in post-operative patients?

• A. Encourage early ambulation
• B. Administer anticoagulants
• C. Apply compression stockings
• D. All of the above

Correct answer: D

Rationale: All of the above options are essential in preventing deep vein thrombosis (DVT) in post-operative patients. Encouraging early ambulation helps prevent blood stasis in the lower extremities, reducing the risk of DVT. Administering anticoagulants can prevent blood clots from forming. Compression stockings promote blood flow, reducing the likelihood of clot formation. Each intervention plays a crucial role in DVT prevention, making the correct answer 'All of the above.' Choices A, B, and C are not exclusive of each other but rather work synergistically to provide comprehensive prevention against DVT.

4. What are the complications of untreated hyperglycemia?

• A. Diabetic ketoacidosis and dehydration
• B. Hypoglycemia and hypertension
• C. Infection and liver failure
• D. Pulmonary edema and electrolyte imbalance

Correct answer: A

Rationale: The correct answer is A: Diabetic ketoacidosis and dehydration. Untreated hyperglycemia can lead to diabetic ketoacidosis, a serious complication characterized by high blood sugar, the presence of ketones in the urine, and acidosis. Dehydration is also a common complication of untreated hyperglycemia. Choices B, C, and D are incorrect because hypoglycemia and hypertension are not typical complications of untreated hyperglycemia. Infection and liver failure, as well as pulmonary edema and electrolyte imbalance, are also not direct complications of untreated hyperglycemia.

5. What are the nursing responsibilities when administering intravenous (IV) antibiotics?

• A. Verify the antibiotic dosage and check for allergies
• B. Administer the medication without verification
• C. Do not check for allergies or dosage
• D. Ensure the patient is allergic to antibiotics

Correct answer: A

Rationale: When administering IV antibiotics, it is essential for the nurse to verify the antibiotic dosage and check for any allergies the patient may have. This is crucial to ensure that the correct medication is being given at the proper dose and to prevent potential adverse reactions. Choice B is incorrect because administering medication without verification can lead to errors. Choice C is incorrect as it goes against safe medication administration practices. Choice D is incorrect as the focus should be on checking if the patient has allergies to antibiotics, not ensuring the patient is allergic to them.

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