Nursing Elites

1. When teaching the guardian of a 12-year-old male client about manifestations of puberty, which of the following physical changes typically occurs first?

• A. Appearance of downy hair on the upper lip
• B. Hair growth in the axillae
• C. Enlargement of the testes and scrotum
• D. Deepening of the voice

Correct answer: C

Rationale: During puberty in males, the first physical change that typically occurs is the enlargement of the testes and scrotum. This change is due to increased production of testosterone, which stimulates growth and development of the genital organs. The appearance of downy hair on the upper lip (Choice A) and hair growth in the axillae (Choice B) usually follow the enlargement of the testes and scrotum. Deepening of the voice (Choice D) is a later stage change that occurs during puberty as the larynx (voice box) grows and the vocal cords lengthen and thicken.

2. The nurse receives a report that a client with an indwelling urinary catheter has an output of 150 mL for the previous 6-hour shift. Which intervention should the nurse implement first?

• A. Check the drainage tubing for a kink
• B. Review the intake and output record
• C. Notify the healthcare provider
• D. Give the client 8 oz of water to drink

Correct answer: A

Rationale: The correct answer is to check the drainage tubing for a kink. A kink in the tubing can obstruct urine flow, potentially causing the low output. By addressing this first, the nurse can ensure that there are no physical obstructions hindering urine drainage. Reviewing the intake and output record is important, but addressing a possible kink in the tubing takes precedence as it directly affects urine flow. Notifying the healthcare provider should be considered after assessing and resolving immediate issues. Giving the client water to drink may be appropriate, but addressing a kink in the tubing is the priority to ensure proper function of the urinary catheter.

3. A client is postoperative following knee arthroplasty and requires the use of a thigh-length sequential compression device. Which of the following actions should the nurse take?

• A. Ensure two fingers can fit under the sleeves.
• B. Ensure the device is not too tight to impede circulation.
• C. Position the client comfortably before applying the device.
• D. Use the device continuously to prevent blood clots.

Correct answer: A

Rationale: The correct action for the nurse to take when applying a thigh-length sequential compression device to a postoperative client is to ensure that two fingers can fit under the sleeves. This action helps prevent the device from being too tight, which could impede circulation. Choice B is incorrect because the device should not be too tight, as it could lead to circulation issues. Choice C is incorrect as the client should be in a comfortable position, not necessarily supine. Choice D is incorrect as sequential compression devices are typically used continuously to prevent blood clots.

4. A client has been admitted to the hospital with severe diarrhea. The nurse should monitor the client for which complication?

• A. Metabolic acidosis
• B. Metabolic alkalosis
• C. Hyperkalemia
• D. Hypercalcemia

Correct answer: A

Rationale: Severe diarrhea can lead to metabolic acidosis due to the loss of bicarbonate. When there is excessive loss of bicarbonate through diarrhea, the pH of the blood decreases, leading to metabolic acidosis. Metabolic alkalosis (Choice B) is not typically associated with severe diarrhea as it involves elevated pH and bicarbonate levels. Hyperkalemia (Choice C) is less likely with severe diarrhea as potassium is often lost along with fluids. Hypercalcemia (Choice D) is not a common complication of severe diarrhea; instead, hypocalcemia may occur due to malabsorption of calcium.

5. A client is experiencing a severe sore throat, pain when swallowing, and swollen lymph nodes. Which of the following stages of infection is the client likely in?

• A. Prodromal
• B. Incubation
• C. Convalescence
• D. Illness

Correct answer: D

Rationale: The client in this scenario is in the illness stage of infection. During this stage, the individual exhibits specific symptoms such as a severe sore throat, pain when swallowing, and swollen lymph nodes. The prodromal stage precedes the appearance of specific symptoms and is characterized by nonspecific signs. The incubation period occurs between exposure to the pathogen and the onset of symptoms. Convalescence is the recovery period following the resolution of the infection. Therefore, the correct answer is 'D: Illness' as it aligns with the symptoms presented by the client.

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