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. A client with early breast cancer receives the results of a breast biopsy and asks the nurse to explain the meaning of staging and the type of receptors found on the cancer cells. Which explanation should the nurse provide?

• A. Lymph node involvement is not significant.
• B. Small tumors are aggressive and indicate poor prognosis.
• C. The tumor's estrogen receptor guides treatment options.
• D. Stage I indicates metastasis.

Correct answer: C

Rationale: Treatment decisions and prediction of prognosis are related to the tumor's receptor status, such as estrogen and progesterone receptor status which commonly are well-differentiated, have a lower chance of recurrence, and are receptive to hormonal therapy. Tumor staging designates tumor size and spread of breast cancer cells into axillary lymph nodes, which is one of the most important prognostic factors in early-stage breast cancer.

3. A nurse is assessing a postoperative client on an hourly basis. The nurse notes that the client’s urine output for the past hour was 25 mL. Based on this finding, the nurse first:

• A. Calls the physician
• B. Increases the rate of the IV infusion
• C. Checks the client’s overall intake and output record
• D. Administers a 250-mL bolus of normal saline solution (0.9%)

Correct answer: C

Rationale: Clients are at risk of hypovolemia postoperatively, and decreased urine output can be an early sign. However, to accurately interpret this finding, the nurse must assess the overall fluid balance by checking the client’s intake and output records. Increasing the IV infusion rate or administering a bolus of normal saline solution without a physician's order would not be appropriate as these interventions require a prescription. The physician should be notified once the nurse has collected all necessary assessment data, including fluid status and vital signs.

4. The nurse is caring for several patients who are receiving antibiotics. Which order will the nurse question?

• A. Azithromycin (Zithromax) 500 mg IV in 500 mL of fluid
• B. Azithromycin (Zithromax) 500 mg PO once daily
• C. Erythromycin 300 mg IM QID
• D. Erythromycin 300 mg PO QID

Correct answer: C

Rationale: The nurse should question the order for Erythromycin 300 mg IM QID. Erythromycin and other macrolides should not be given intramuscularly because they cause painful tissue irritation. Options A and B are correct routes for Azithromycin, either intravenously or orally. Option D is a correct route for Erythromycin, which is orally.

5. A client with autosomal dominant polycystic kidney disease (ADPKD) asks, “Will my children develop this disease?” How should the nurse respond?

• A. No genetic link is known, so your children are not at increased risk.
• B. Your sons will develop this disease because it has a sex-linked gene.
• C. Only if both you and your spouse are carriers of this disease.
• D. Each of your children has a 50% risk of having ADPKD.

Correct answer: D

Rationale: Children whose parent has the autosomal dominant form of PKD have a 50% chance of inheriting the gene that causes the disease. ADPKD is transmitted as an autosomal dominant trait and therefore is not gender-specific. Both parents do not need to have this disorder. Choice A is incorrect because ADPKD has a known genetic link and a definitive mode of inheritance. Choice B is incorrect as ADPKD is not sex-linked but autosomal dominant. Choice C is incorrect because ADPKD follows an autosomal dominant inheritance pattern and does not require both parents to be carriers for the child to inherit the disease.

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