Nursing Elites

1. A client is starting urinary bladder training. Which statement should the nurse include in this client’s teaching?

• A. Use the toilet when you first feel the urge, rather than at specific intervals.
• B. Try to consciously hold your urine until the scheduled toileting time.
• C. Initially try to use the toilet at least every half hour for the first 24 hours.
• D. The toileting interval can be increased once you have been continent for a week.

Correct answer: B

Rationale: In urinary bladder training, the client should be taught to try to consciously hold their urine until the scheduled toileting time. This helps in training the bladder to hold urine for longer periods. Option A is incorrect because the goal is to consciously hold urine, not void immediately. Option C is incorrect as toileting at least every half hour may not promote bladder training. Option D is incorrect as increasing the toileting interval should be based on the client's comfort and progress, not just after being continent for a week.

2. Which of the following is the best indicator of long-term glycemic control in a patient with diabetes?

• A. Fasting blood glucose levels.
• B. Postprandial blood glucose levels.
• C. Hemoglobin A1c.
• D. Random blood glucose levels.

Correct answer: C

Rationale: The correct answer is C, Hemoglobin A1c. Hemoglobin A1c measures the average blood glucose level over the past 2-3 months, providing a reliable indicator of long-term glycemic control. Fasting blood glucose levels (choice A) only offer a snapshot of the current glucose level and can fluctuate throughout the day. Postprandial blood glucose levels (choice B) reflect glucose levels after meals but do not give a comprehensive view of long-term control. Random blood glucose levels (choice D) are taken at any time and lack the consistency needed to assess long-term glycemic control effectively. Therefore, Hemoglobin A1c is the superior choice for monitoring and managing diabetes over an extended period.

3. A client has just returned to the nursing unit after computerized tomography (CT) with contrast medium. Which of the following actions should the nurse plan to take as part of routine after-care for this client?

• A. Administering a laxative
• B. Encouraging fluid intake
• C. Maintaining the client on strict bed rest
• D. Holding all medications for at least 2 hours

Correct answer: B

Rationale: After CT scanning with contrast medium, the client does not require special restrictions or interventions. Encouraging fluid intake is important to help flush out the contrast dye and prevent dehydration. Administering a laxative (Choice A) is unnecessary and not indicated after CT with contrast. Maintaining the client on strict bed rest (Choice C) is not necessary unless specified by the healthcare provider. Holding all medications for at least 2 hours (Choice D) is not a standard practice after CT with contrast.

4. The client with chronic renal failure is receiving peritoneal dialysis. Which of the following is the most important action for the nurse to take?

• A. Administer the prescribed antibiotics.
• B. Monitor for signs of infection.
• C. Encourage the client to increase fluid intake.
• D. Monitor the client's weight daily.

Correct answer: B

Rationale: Monitoring for signs of infection is crucial in clients undergoing peritoneal dialysis. Peritonitis is a severe complication associated with peritoneal dialysis, making it essential to promptly identify any signs of infection, such as abdominal pain, cloudy dialysate, fever, and an elevated white blood cell count. Administering antibiotics without proper assessment can lead to antibiotic resistance and should not be the initial action. Encouraging increased fluid intake may not be appropriate without assessing the client's fluid status. Monitoring weight alone does not address the immediate risk of peritonitis in a client undergoing peritoneal dialysis.

5. A client is being prepared for transfer to the operating room. Which of the following actions should the nurse take in the care of this client at this time?

• A. Ensuring that the client has voided
• B. Administering all daily medications
• C. Practicing postoperative breathing exercises
• D. Verifying that the client has not eaten for the last 24 hours

Correct answer: A

Rationale: The nurse should ensure that the client has voided, especially if a Foley catheter is not in place. This step is important to prevent urinary retention during the surgical procedure. Administering all daily medications just before surgery is not standard practice. The physician typically provides specific orders regarding which medications can be taken with a sip of water before surgery. Postoperative breathing exercises are usually taught after surgery to prevent complications like atelectasis. Verifying that the client has not eaten for the last 24 hours is not a standard preoperative practice; instead, the client is usually instructed to fast for a specific period before surgery to reduce the risk of aspiration during anesthesia.

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