Nursing Elites

1. The nurse assesses a client who is newly diagnosed with hyperthyroidism and observes that the client's eyeballs are protuberant, causing a wide-eyed appearance and eye discomfort. Based on this finding, which action should the nurse include in the client's plan of care?

• A. Assess for signs of increased intracranial pressure
• B. Prepare to administer intravenous levothyroxine
• C. Review the client's serum electrolyte values
• D. Obtain a prescription for artificial tear drops

Correct answer: D

Rationale: In hyperthyroidism, eye discomfort due to protuberant eyeballs (exophthalmos) can be alleviated by using artificial tear drops. These drops help prevent complications associated with dry eyes and promote comfort. Assessing for signs of increased intracranial pressure (Choice A) is not directly related to the client's eye discomfort from hyperthyroidism. Administering intravenous levothyroxine (Choice B) is not the appropriate intervention for managing eye discomfort in hyperthyroidism. Reviewing serum electrolyte values (Choice C) is important in hyperthyroidism but is not directly addressing the client's current eye discomfort and protuberant eyeballs.

2. A client’s baseline vital signs are temperature 98°F oral, pulse 74 beats/min, respiratory rate 18 breaths/min, and blood pressure 124/76 mm Hg. The client suddenly spikes a fever to 103°F. Which of the following respiratory rates would the nurse anticipate as part of the body’s response to the change in client status?

• A. 12 breaths/min
• B. 16 breaths/min
• C. 18 breaths/min
• D. 22 breaths/min

Correct answer: D

Rationale: When a client experiences a fever, there is an increase in body temperature, leading to a higher metabolic rate and oxygen demand. As a result, the respiratory rate typically increases to meet the body's increased oxygen needs. Therefore, in response to the fever spike from 98°F to 103°F, the nurse would anticipate a higher respiratory rate. Choices A, B, and C are incorrect because a decrease in body temperature, not an increase as seen in fever, would lead to a decrease in respiratory rate to conserve energy and oxygen consumption.

3. A client who was in a motor vehicle collision was admitted to the hospital, and the right knee was placed in skeletal traction. The nurse has documented this nursing diagnosis in the client's medical record: 'Potential for impairment of skin integrity related to immobility from traction.' Which nursing intervention is indicated based on this diagnosis statement?

• A. Release the traction every 4 hours to provide skin care.
• B. Turn the client for back care while suspending traction.
• C. Provide back and skin care while maintaining the traction.
• D. Give back care after the client is released from traction.

Correct answer: C

Rationale: The correct nursing intervention indicated based on the nursing diagnosis 'Potential for impairment of skin integrity related to immobility from traction' is to provide back and skin care while maintaining the traction. This intervention is crucial for maintaining the client's skin integrity and preventing potential complications. Releasing the traction every 4 hours (Choice A) may disrupt the treatment plan and compromise the effectiveness of traction. Turning the client for back care while suspending traction (Choice B) does not address the need for skin care while the client is in traction. Giving back care after the client is released from traction (Choice D) neglects the immediate need to prevent skin impairment while in traction. Therefore, providing back and skin care while maintaining the traction (Choice C) is the most appropriate intervention in this scenario.

4. 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.

5. A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for bladder cancer?

• A. A 25-year-old female with a history of sexually transmitted diseases
• B. A 42-year-old male who has worked in a lumber yard for 10 years
• C. A 55-year-old female who has had numerous episodes of bacterial cystitis
• D. An 86-year-old male with a 50–pack-year cigarette smoking history

Correct answer: D

Rationale: The correct answer is D. The greatest risk factor for bladder cancer is a long history of tobacco use, which is reflected in an 86-year-old male with a 50–pack-year cigarette smoking history. Smoking is a well-established risk factor for developing bladder cancer. Choices A, B, and C are not directly linked to an increased risk of bladder cancer. While sexually transmitted diseases, certain occupational exposures, and recurrent urinary tract infections may pose other health risks, they are not specifically associated with an elevated risk of bladder cancer.

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