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. A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy protocol that includes methotrexate, an antimetabolite. Which information should the nurse provide the parents about caring for their child?

• A. Use sunblock or protective clothing when outdoors.
• B. Include the child in regular outings with the family.
• C. Obtain any childhood vaccinations that are not up-to-date.
• D. Use diluted commercial mouthwash for mouth care.

Correct answer: A

Rationale: The correct answer is to use sunblock or protective clothing when outdoors. Methotrexate can cause photosensitivity, making the child more prone to sunburns and skin damage. Therefore, advising the parents to protect their child's skin from direct sunlight exposure is crucial. Choice B is incorrect because exposing the child to direct sunlight without protection can worsen the photosensitivity caused by methotrexate. Choice C is incorrect as obtaining vaccinations is generally avoided during chemotherapy due to the child's compromised immune system. Choice D is incorrect as commercial mouthwash may contain alcohol, which can be irritating to the child's oral mucosa, especially during chemotherapy.

3. A hospitalized toddler who is recovering from a sickle cell crisis holds a toy and says, 'Mine.' According to Erikson's theory of psychosocial development, this child's behavior is a demonstration of which developmental stage?

• A. Autonomy vs. Shame and Doubt
• B. Industry vs. Inferiority
• C. Initiative vs. Guilt
• D. Trust vs. Mistrust

Correct answer: A

Rationale: The toddler's behavior of asserting possession ('Mine') reflects a desire for independence, aligning with Erikson's stage of Autonomy vs. Shame and Doubt. This stage, typical for toddlers aged 1-3 years, focuses on developing a sense of control and independence. Choices B, C, and D are incorrect: Industry vs. Inferiority relates to middle childhood, Initiative vs. Guilt pertains to preschoolers, and Trust vs. Mistrust is associated with infancy.

4. After receiving a report, the nurse receives the laboratory values for four clients. Which client requires the nurse’s immediate intervention? The client who is...

• A. Short of breath after a shower and has a hemoglobin of 8 grams
• B. Bleeding from a finger stick and has a prothrombin time of 30 seconds
• C. Febrile and has a WBC count of 14,000/mm3
• D. Trembling and has a glucose level of 50 mg/dL

Correct answer: D

Rationale: A glucose level of 50 mg/dL is indicative of hypoglycemia, which requires immediate intervention to prevent further complications. Hypoglycemia can lead to serious consequences such as altered mental status, seizures, and even coma if not promptly addressed. The other options do not present immediate life-threatening conditions that require urgent intervention. Shortness of breath with a hemoglobin of 8 grams may indicate anemia but does not require immediate intervention. Bleeding from a finger stick with a prothrombin time of 30 seconds may suggest clotting issues, which are important but not as immediately critical as hypoglycemia. Being febrile with an elevated WBC count could indicate infection, which is concerning but not as urgently critical as hypoglycemia.

5. A client with asthma is prescribed an albuterol inhaler. Which instruction should the nurse provide?

• A. Use the inhaler only during an asthma attack
• B. Rinse your mouth after using the inhaler
• C. Shake the inhaler before each use
• D. Exhale fully before inhaling the medication

Correct answer: C

Rationale: The correct instruction for the nurse to provide is to shake the inhaler before each use. Shaking the inhaler ensures proper mixing of the medication before administration, which is crucial for its effectiveness. Choice A is incorrect because albuterol inhalers are often used as a preventive measure, not just during asthma attacks. Choice B is a good practice to prevent oral fungal infections associated with inhaled corticosteroids, not typically with albuterol. Choice D is important for proper inhaler technique, but the primary step before inhaling is shaking the inhaler to ensure the medication is well mixed.

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