Nursing Elites

1. A client is being taught about self-catheterization in the home setting. Which statements should the nurse include in this client’s teaching? (Select all that apply.)

• A. Wash your hands before and after self-catheterization.
• B. Use lubricant on the tip of the catheter before insertion.
• C. A & B
• D. Self-catheterize at least twice a day or every 12 hours.

Correct answer: C

Rationale: In teaching a client about self-catheterization, it is essential to emphasize proper hand hygiene before and after the procedure to prevent infections. Using lubricant on the catheter helps with insertion and reduces discomfort. Therefore, statements A and B are correct and should be included in the client's teaching. Option D is incorrect because self-catheterization frequency should be individualized based on the client's needs, and a specific time frame like every 12 hours may not be suitable for everyone. Choosing a smaller lumen catheter is preferred over a larger one. Self-catheterization should not be limited to a specific time frame but should be based on the individual's needs and voiding patterns. Therefore, option C is the correct choice as it includes the two essential statements for teaching self-catheterization in the home setting.

2. The client with chronic renal failure is being taught about the importance of fluid restrictions. Which of the following statements by the client indicates that the teaching has been effective?

• A. I can drink as much fluid as I want, as long as I take my medication.
• B. I will need to limit my fluid intake to prevent fluid overload.
• C. I can drink as much water as I want, as long as I limit other fluids.
• D. I will need to drink only when I am thirsty.

Correct answer: B

Rationale: The correct answer is B: 'I will need to limit my fluid intake to prevent fluid overload.' In chronic renal failure, fluid restrictions are crucial to prevent fluid overload and further damage to the kidneys. Option A is incorrect as unrestricted fluid intake can worsen the condition. Option C is also incorrect as total fluid intake needs to be restricted, not just other fluids. Option D is not ideal because thirst may not accurately reflect the body's fluid needs in chronic renal failure.

3. The healthcare provider is caring for a patient who is receiving an intravenous antibiotic. The patient has a serum drug trough of 1.5 mcg/mL. The normal trough for this drug is 1.7 mcg/mL to 2.2 mcg/mL. What will the healthcare provider expect the patient to experience?

• A. Inadequate drug effects
• B. Increased risk of superinfection
• C. Minimal adverse effects
• D. Slowed onset of action

Correct answer: A

Rationale: A serum drug trough level below the normal range (1.7 mcg/mL to 2.2 mcg/mL) indicates that the medication concentration is insufficient to provide therapeutic effects, leading to inadequate drug effects. A low trough level does not directly correlate with an increased risk of superinfection, minimal adverse effects, or a slowed onset of action, as these are more related to the drug's concentration within the therapeutic range.

4. The healthcare provider notes a blood pressure of 160/90 mm Hg in a patient taking a thiazide diuretic. The patient reports taking an herbal medication that a friend recommended. Which herbal product is likely, given this patient’s blood pressure?

• A. Ginkgo
• B. Hawthorn
• C. Licorice
• D. St. John’s wort

Correct answer: A

Rationale: The correct answer is A: Ginkgo. Increased blood pressure can result when ginkgo is used in combination with a thiazide diuretic. Option B (Hawthorn) is incorrect because hawthorn is more commonly associated with lowering blood pressure. Option C (Licorice) is incorrect because licorice can lead to sodium and water retention, potentially exacerbating hypertension. Option D (St. John’s wort) is incorrect as it is not typically associated with significant blood pressure effects.

5. When planning care for a client newly diagnosed with open-angle glaucoma, the nurse identifies a priority nursing problem of 'visual sensory/perceptual alterations.' This problem is based on which etiology?

• A. Blurred distance vision
• B. Limited eye movement
• C. Decreased peripheral vision
• D. Photosensitivity

Correct answer: C

Rationale: The correct answer is 'C: Decreased peripheral vision.' Open-angle glaucoma leads to a gradual loss of peripheral vision due to damage to the optic nerve. This loss of peripheral vision is a hallmark sign of the condition and a primary reason for the visual sensory/perceptual alterations experienced by the client. Blurred distance vision (choice A) may occur but is not the priority nursing problem. Limited eye movement (choice B) and photosensitivity (choice D) are not typically associated with the sensory/perceptual alterations seen in open-angle glaucoma.

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