Nursing Elites

1. The nurse is assessing an older resident with a history of Benign Prostatic Hypertrophy and identifies a distended bladder. What should the nurse do?

• A. Stand the client to void and run tap water within hearing distance before catheterizing
• B. Straight catheterize and if the residual urine volume is greater than 100 mL, clamp catheter
• C. Catheterize q2h and place in an indwelling catheter at the end of the prescribed 24hr period
• D. Catheterize with an indwelling catheter and if the residual volume is greater than 100 mL, inflate the balloon

Correct answer: D

Rationale: Prompt and appropriate management of urinary retention prevents complications like infection and bladder damage.

2. The client with a new diagnosis of type 2 diabetes is being taught about diet management by the nurse. Which statement by the client indicates effective learning?

• A. I should not avoid all carbohydrates
• B. I can eat whatever I want as long as I take my medication
• C. I need to eat regular meals and snacks to maintain my blood sugar levels
• D. I will decrease my intake of sugary foods to prevent low blood sugar

Correct answer: C

Rationale: Choice C is the correct answer because eating regular meals and snacks is crucial for maintaining stable blood sugar levels in individuals with diabetes. This approach helps prevent spikes and drops in blood sugar, promoting better management of the condition. Choices A, B, and D are incorrect. Avoiding all carbohydrates is not recommended as they are a major energy source and can be part of a balanced diet; eating whatever one wants while relying solely on medication can lead to uncontrolled blood sugar levels and complications; decreasing sugary foods intake can actually contribute to high blood sugar levels rather than preventing low blood sugar.

3. The healthcare provider is assessing a client who has just undergone a thoracentesis. Which finding should be reported immediately?

• A. Diminished breath sounds on the affected side.
• B. Pain at the procedure site.
• C. Blood-tinged sputum.
• D. Shortness of breath.

Correct answer: D

Rationale: Shortness of breath should be reported immediately as it may indicate a pneumothorax, a potential complication of thoracentesis. Diminished breath sounds on the affected side, pain at the procedure site, and blood-tinged sputum are common findings post-thoracentesis and do not necessarily indicate immediate complications like a pneumothorax.

4. The nurse is palpating the right upper hypochondriac region of the abdomen of a client. What organ lies underneath this area?

• A. Duodenum
• B. Gastric pylorus
• C. Liver
• D. Spleen

Correct answer: C

Rationale: The correct answer is C: Liver. The liver is located in the right upper hypochondriac region of the abdomen. The duodenum (Choice A) is located in the right upper quadrant but not directly underneath the right upper hypochondriac region. The gastric pylorus (Choice B) is part of the stomach and is located more centrally in the abdomen. The spleen (Choice D) is located in the left upper quadrant of the abdomen, not underneath the right upper hypochondriac region.

5. A client with a history of hypertension is prescribed hydrochlorothiazide (HCTZ). Which adverse effect should the nurse monitor for?

• A. Hyperkalemia
• B. Hyponatremia
• C. Bradycardia
• D. Hyperglycemia

Correct answer: B

Rationale: The correct answer is 'B. Hyponatremia.' Hydrochlorothiazide can lead to electrolyte imbalances, such as hyponatremia, due to its diuretic effect. This potential adverse effect should be closely monitored in patients taking HCTZ. Choice A, hyperkalemia, is less likely to occur with HCTZ as it tends to cause hypokalemia. Choice C, bradycardia, is not a common adverse effect of HCTZ. Choice D, hyperglycemia, is also less commonly associated with HCTZ use compared to hyponatremia.

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