Nursing Elites

1. The nurse instructs the unlicensed nursing personnel (UAP) on how to provide oral hygiene for clients who cannot perform this task for themselves. Which of the following techniques should the nurse tell the UAP to incorporate into the client's daily care?

• A. Assess the oral cavity each time mouth care is given and record observations.
• B. Use a soft toothbrush to brush the client's teeth after each meal.
• C. Swab the client's tongue, gums, and lips with a soft foam applicator every 2 hours.
• D. Rinse the client's mouth with mouthwash several times a day.

Correct answer: B

Rationale: The correct technique to incorporate into the client's daily care for oral hygiene is to use a soft toothbrush to brush the client's teeth after each meal. This helps in maintaining oral hygiene for clients who cannot perform this task themselves. Choice A is incorrect because assessing the oral cavity each time mouth care is given is important but not the technique to incorporate into daily care. Choice C is incorrect as swabbing the tongue, gums, and lips every 2 hours may not be necessary for daily care. Choice D is incorrect as rinsing the client's mouth with mouthwash several times a day may not be suitable for all clients and is not a standard recommendation for daily oral care.

2. The nurse is teaching the main principles of hemodialysis to a client with chronic kidney disease. Which statement by the client indicates a need for further teaching by the nurse?

• A. My sodium level changes due to the movement from the blood into the dialysate.
• B. Dialysis works by the movement of wastes from higher to lower concentration.
• C. Extra fluid can be pulled from the blood by osmosis.
• D. The dialysate is similar to blood but without any toxins.

Correct answer: B

Rationale: The correct answer is B because dialysis works by the movement of solutes from an area of higher concentration to an area of lower concentration, which is known as diffusion. The other statements are accurate: A correctly describes the movement of sodium during hemodialysis, C explains the removal of excess fluid by osmosis, and D highlights the purpose of the dialysate in removing toxins from the blood.

3. The nurse is providing discharge teaching for a patient who will receive oral levofloxacin (Levaquin) to treat pneumonia. The patient takes an oral hypoglycemic medication and uses over-the-counter (OTC) antacids to treat occasional heartburn. The patient reports frequent arthritis pain and takes acetaminophen when needed. Which statement by the nurse is correct when teaching this patient?

• A. You may take antacids with levofloxacin to decrease gastrointestinal upset.
• B. You may take nonsteroidal anti-inflammatory medications (NSAIDs) for arthritis pain.
• C. You should monitor your serum glucose more closely while taking levofloxacin.
• D. You should take levofloxacin on an empty stomach to improve absorption.

Correct answer: C

Rationale: Levofloxacin may increase the effects of oral hypoglycemic medications, so patients taking these should be advised to monitor their serum glucose levels closely.

4. A client with cirrhosis develops increasing pedal edema and ascites. What dietary modification is most important for the nurse to teach this client?

• A. Avoid high carbohydrate foods.
• B. Decrease intake of fat-soluble vitamins.
• C. Decrease caloric intake.
• D. Restrict salt and fluid intake.

Correct answer: D

Rationale: The correct answer is to restrict salt and fluid intake. In clients with cirrhosis presenting with pedal edema and ascites, excessive fluid retention occurs, necessitating the restriction of salt and fluid to alleviate these symptoms. Choice A, avoiding high carbohydrate foods, is not the priority in this situation. Decreasing intake of fat-soluble vitamins (Choice B) is not specifically indicated for managing edema and ascites in cirrhosis. While maintaining an appropriate caloric intake is important, decreasing caloric intake (Choice C) is not the primary focus when addressing fluid retention in cirrhosis.

5. A client presents with a fungal urinary tract infection (UTI). Which assessments should the nurse complete? (Select all that apply.)

• A. Palpate the kidneys and bladder.
• B. Assess the medical history and current medical problems.
• C. Perform a bladder scan to assess post-void residual.
• D. Inquire about recent travel to foreign countries.

Correct answer: B

Rationale: When assessing a client with a fungal UTI, the nurse should prioritize gathering information related to the medical history and current medical problems. Clients who are severely immunocompromised or have conditions like diabetes mellitus are more susceptible to fungal UTIs. Assessing the medical history helps identify risk factors and potential causes of the infection. While physical examinations like palpating the kidneys and bladder and performing a bladder scan may be necessary, they should follow the initial assessment of medical history. Inquiring about recent travel to foreign countries is less relevant in the context of a fungal UTI, as the focus should be on immediate medical factors predisposing the client to the infection.

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