Nursing Elites

1. After delegating care to an unlicensed assistive personnel (UAP) for a client who is prescribed habit training to manage incontinence, a nurse evaluates the UAP’s understanding. Which action indicates the UAP needs additional teaching?

• A. Toileting the client after breakfast
• B. Changing the client’s incontinence brief when wet
• C. Encouraging the client to drink fluids
• D. Recording the client’s incontinence episodes

Correct answer: B

Rationale: The correct action that indicates the UAP needs additional teaching is choice B, 'Changing the client’s incontinence brief when wet.' Habit training is a technique used to manage incontinence, and it is undermined by the use of absorbent incontinence briefs or pads. The nurse should re-educate the UAP on the technique of habit training, which involves scheduled toileting and promoting bladder control. Choices A, C, and D are appropriate actions that support the client’s care: toileting the client after meals, encouraging fluid intake, and documenting incontinence episodes are all important aspects of managing incontinence and monitoring the client's condition.

2. A client has just returned to the nursing unit after bronchoscopy. To which intervention should the nurse give priority?

• A. Assessing the client for the return of the gag reflex
• B. Administering pain medication
• C. Encouraging copious fluid intake
• D. Ambulating the client

Correct answer: A

Rationale: After bronchoscopy, the priority intervention for the nurse is to assess the client for the return of the gag reflex. This assessment is crucial to ensure the client's safety and prevent aspiration. Keeping the client on nothing-by-mouth status until the gag reflex returns is essential. Administering pain medication, encouraging fluid intake, and ambulating the client are important interventions but assessing the gag reflex takes precedence due to the risk of aspiration post-bronchoscopy.

3. The client is planning care for a client who is receiving hemodialysis. Which of the following interventions should be included in the plan of care?

• A. Administer anticoagulants to prevent clot formation.
• B. Monitor the client for signs of infection.
• C. Provide the client with a high-protein diet.
• D. Encourage the client to drink at least 2 liters of fluid daily.

Correct answer: B

Rationale: Monitoring for signs of infection is crucial in clients receiving hemodialysis because they are at an increased risk of infection due to the invasive nature of the procedure. Administering anticoagulants is not typically a part of the routine care for clients undergoing hemodialysis unless specifically prescribed. While a high-protein diet may be beneficial for some clients, it is not a specific intervention related to hemodialysis. Encouraging fluid intake must be individualized based on the client's fluid status and should not be a generalized recommendation for all clients receiving hemodialysis.

4. Which food is most important to encourage a client with osteomalacia to include in a daily diet?

• A. Fortified milk and cereals
• B. Citrus fruits and juices
• C. Green leafy vegetables
• D. Red meats and eggs

Correct answer: A

Rationale: The correct answer is A: Fortified milk and cereals. Osteomalacia is a condition caused by a deficiency in vitamin D. Fortified milk and cereals are rich sources of vitamin D, which is essential for managing osteomalacia. Citrus fruits and juices (choice B) are high in vitamin C, but vitamin D is the primary concern for osteomalacia. Green leafy vegetables (choice C) are good sources of various nutrients but not the main focus for managing osteomalacia. Red meats and eggs (choice D) are good sources of protein and other nutrients but are not as critical as fortified milk and cereals for addressing vitamin D deficiency in osteomalacia.

5. The nurse is caring for a patient who develops marked edema and a low urine output as a result of heart failure. Which medication will the nurse expect the provider to order for this patient?

• A. Digoxin (Lanoxin)
• B. Furosemide (Lasix)
• C. Hydrochlorothiazide (HydroDIURIL)
• D. Spironolactone (Aldactone)

Correct answer: B

Rationale: In heart failure with marked edema and low urine output, the nurse can expect the provider to order Furosemide (Lasix). Furosemide is a loop diuretic that acts quickly to remove excess fluid from the body, making it an appropriate choice for this patient's condition. Digoxin is used to improve heart function but does not directly address fluid overload. Hydrochlorothiazide is a thiazide diuretic that is not as potent as Furosemide in managing acute fluid retention. Spironolactone is a potassium-sparing diuretic that is typically used in heart failure for its aldosterone-blocking effects and not for immediate fluid removal.

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