Nursing Elites

1. In a routine sputum analysis, which of the following indicates proper nursing action before sputum collection?

• A. Secure a clean container
• B. Discard the container if the outside becomes soiled
• C. Rinse the client's mouth with water after collection
• D. Tell the client that 4 tablespoons of sputum are needed

Correct answer: A

Rationale: Corrected Rationale: Before sputum collection, it is crucial to use a clean container to prevent specimen contamination. This step is essential to ensure accurate test results and to avoid introducing external particles or bacteria into the sample. Choice B is incorrect because discarding the container if the outside becomes soiled is not a standard practice before collection. Choice C is incorrect as rinsing the client's mouth with Listerine after collection can introduce unnecessary substances into the specimen. Choice D is incorrect as the amount of sputum needed should be determined by the healthcare provider, not the client.

2. The nurse is teaching a community class to people with Type 2 diabetes mellitus. Which explanation would explain the development of Type 2 diabetes?

• A. The islet cells in the pancreas stop producing insulin
• B. The client eats too many foods that are high in sugar
• C. The pituitary gland does not produce vasopressin
• D. The cells become resistant to the circulating insulin

Correct answer: D

Rationale: The correct answer is D. In Type 2 diabetes, the primary issue is insulin resistance, where cells do not respond effectively to insulin. Choice A is incorrect because in Type 1 diabetes, the islet cells in the pancreas stop producing insulin. Choice B is not directly related to the development of Type 2 diabetes but rather to its management. Choice C is incorrect as it refers to a dysfunction in vasopressin production, which is not related to Type 2 diabetes.

3. Participating in the development of long-term and preventive health goals with the patient and their family is a part of which of the following steps for determining and fulfilling the nursing care needs of the patient?

• A. Evaluation
• B. Planning
• C. Implementation
• D. Assessment

Correct answer: B

Rationale: The correct answer is B: Planning. In the nursing process, planning involves developing long-term and preventive health goals in collaboration with the patient and their family. This step focuses on outlining the strategies and interventions needed to achieve the desired outcomes. Choice A, Evaluation, occurs after interventions are implemented to assess the effectiveness of the care provided. Choice C, Implementation, involves carrying out the planned interventions. Choice D, Assessment, is the initial step in the nursing process that involves collecting data to identify the patient's needs and health status.

4. The nurse in the pediatric clinic performs a physical assessment of a 13-year-old boy. Which of the following findings by the nurse requires an immediate intervention?

• A. The adolescent complains of his scrotum aching after exercise. The nurse palpates a worm-like mass above the testes
• B. The nurse noted unilateral breast enlargement
• C. The child’s scrotum appears swollen, and a soft mass is palpated. The nurse is unable to insert a finger above the mass
• D. The child’s scrotum appears enlarged and red. The nurse palpated a thickened and swollen spermatic cord.

Correct answer: D

Rationale: A swollen and thickened spermatic cord could indicate testicular torsion, which is a surgical emergency.

5. For a patient on lithium therapy, which dietary recommendation is essential?

• A. Increase caffeine intake
• B. Increase sodium intake
• C. Increase protein intake
• D. Increase fiber intake

Correct answer: B

Rationale: The correct answer is to increase sodium intake. Maintaining consistent sodium levels is crucial for patients on lithium therapy to prevent fluctuations in drug levels. Increasing caffeine intake (Choice A) is not recommended as it can interfere with lithium levels. While protein intake (Choice C) is important, it is not the essential dietary recommendation for patients on lithium therapy. Similarly, increasing fiber intake (Choice D) is not a key recommendation for these patients.

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