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. The client is receiving teletherapy radiation for a malignant tumor. Which instruction regarding skin care of the portal site should the nurse provide?

• A. Protect the skin of the radiation portal site from sunlight exposure
• B. Apply moisturizing lotions daily to the radiation portal site
• C. Avoid washing the skin inside the radiation portal site
• D. Remove the ink marks of the portal after each radiation treatment

Correct answer: A

Rationale: Protecting the skin from sunlight exposure is crucial to prevent radiation burns and additional skin damage at the treatment site. Sun exposure can exacerbate skin reactions caused by radiation therapy. Applying moisturizing lotions daily may introduce foreign substances or irritants to the treated area, leading to potential complications. Washing the skin inside the radiation portal site is important for maintaining cleanliness and preventing infections. Removing the ink marks after each treatment is unnecessary and may cause unnecessary skin irritation and trauma.

3. A nurse teaches clients about the difference between urge incontinence and stress incontinence. Which statements should the nurse include in this education? (Select all that apply.)

• A. Urge incontinence involves a post-void residual volume less than 50 mL.
• B. Stress incontinence occurs due to weak pelvic floor muscles.
• C. Stress incontinence usually occurs in people with dementia.
• D. Urge incontinence can be managed by increasing fluid intake.

Correct answer: B

Rationale: The correct statement to include in the education about urge incontinence and stress incontinence is choice B. Stress incontinence occurs due to weak pelvic floor muscles or urethral sphincter, leading to the inability to tighten the urethra sufficiently to overcome increased detrusor pressure. This condition is common after childbirth when pelvic muscles are stretched and weakened. Urge incontinence, on the other hand, is characterized by the inability to suppress the contraction signal from the detrusor muscle. It is often associated with abnormal detrusor contractions, which can be due to neurological abnormalities rather than post-void residual volume. Choice A is incorrect because urge incontinence is not defined by post-void residual volume. Choice C is incorrect as stress incontinence is not usually linked to dementia. Choice D is incorrect because increasing fluid intake is not a management strategy for urge incontinence.

4. Which of the following is the best position for a patient experiencing dyspnea?

• A. Supine position.
• B. Fowler's position.
• C. Trendelenburg position.
• D. Lateral recumbent position.

Correct answer: B

Rationale: Fowler's position is the best position for a patient experiencing dyspnea. This position involves sitting the patient upright with the head of the bed elevated between 45-60 degrees. Fowler's position helps improve breathing in patients with dyspnea by promoting lung expansion, aiding in better oxygenation, and reducing the work of breathing. The supine position (Choice A) may worsen dyspnea by limiting lung expansion. The Trendelenburg position (Choice C) with the feet elevated and the head down is not recommended for dyspnea as it can increase pressure on the chest and compromise breathing. The lateral recumbent position (Choice D) is not ideal for dyspnea as it does not provide optimal lung expansion and may not alleviate breathing difficulty.

5. When a young client being taught to use an inhaler for asthma symptoms states the intention to use the inhaler but plans to continue smoking cigarettes, what is the best initial action by the nurse?

• A. Inform the healthcare provider of the client's statement.
• B. Explain that denial of illness can interfere with the treatment regimen.
• C. Revise the plan of care based on the client's plans to continue smoking.
• D. Review factors surrounding the client's beliefs about smoking cessation.

Correct answer: B

Rationale: The best initial action by the nurse when a client expresses plans to use an inhaler for asthma symptoms but continue smoking cigarettes is to address denial. By explaining that denial of illness can interfere with the treatment regimen, the nurse educates the client about the impact of smoking on asthma treatment. This approach helps the client understand the importance of smoking cessation in managing asthma symptoms. Informing the healthcare provider (Choice A) may be necessary but is not the initial action in this scenario. Revising the plan of care (Choice C) should be considered after addressing the client's denial and educating them. Reviewing factors surrounding the client's beliefs about smoking cessation (Choice D) is relevant but not the best initial action when denial is identified.

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