Nursing Elites

1. The nurse is preparing a female client for discharge after being treated for a urinary tract infection (UTI). Which statement by the client indicates a need for further teaching?

• A. I will use douches regularly to prevent future infections.
• B. I should drink at least 8 glasses of water a day.
• C. I should avoid tight-fitting clothing.
• D. I will wipe from front to back after using the toilet.

Correct answer: A

Rationale: The correct answer is A. Using douches is not recommended as it can disrupt the natural flora and increase the risk of infections. Choices B, C, and D are all correct statements that can help prevent UTIs. Drinking an adequate amount of water helps flush out bacteria, avoiding tight-fitting clothing promotes ventilation and reduces moisture, and wiping from front to back prevents the spread of bacteria from the anal region to the urethra.

2. What are the primary pathophysiological mechanisms responsible for ascites in liver failure?

• A. Decreased liver enzymes.
• B. Increased hydrostatic pressure in portal circulation.
• C. High bilirubin levels.
• D. Fluid shifts due to decreased serum proteins.

Correct answer: B

Rationale: The correct answer is B: Increased hydrostatic pressure in portal circulation. Ascites in liver failure is primarily caused by fluid shifts from the intravascular space to the interstitial space due to increased hydrostatic pressure in the portal circulation. Choice A is incorrect as ascites is not caused by decreased liver enzymes. Choice C is incorrect as high bilirubin levels are not the primary mechanism for ascites in liver failure. Choice D is incorrect as fluid shifts in ascites are due to decreased serum proteins, not increased serum proteins.

3. The nurse is administering a new medication to a client. What is the priority action before administering the drug?

• A. Verify the client's allergies
• B. Check the client's blood pressure
• C. Assess the client's pain level
• D. Provide client education on the medication

Correct answer: A

Rationale: Verifying the client's allergies is the priority action before administering any medication. It is crucial to identify any known allergies to prevent potential allergic reactions, which can be severe and life-threatening. Checking the client's blood pressure, assessing pain levels, and providing education on the medication are important aspects of client care but verifying allergies is essential for ensuring the safety of the client.

4. A client in labor is experiencing late decelerations in fetal heart rate. What intervention should the nurse perform first?

• A. Reposition the client onto her left side.
• B. Apply oxygen via nasal cannula.
• C. Prepare for an emergency cesarean section.
• D. Increase IV fluid administration to improve perfusion.

Correct answer: A

Rationale: Late decelerations indicate fetal distress due to compromised placental perfusion. Repositioning the client onto her left side is the priority intervention as it can increase blood flow to the placenta, improving fetal oxygenation. Applying oxygen via nasal cannula (choice B) can be the next step after repositioning if late decelerations persist. Emergency cesarean section (choice C) is not the initial action for late decelerations unless other interventions are ineffective. Increasing IV fluid administration (choice D) is not the first-line intervention for late decelerations; repositioning takes precedence to address the underlying cause.

5. A client with diabetes mellitus presents with a blood sugar level of 320 mg/dL. What is the nurse's initial action?

• A. Administer sliding scale insulin as prescribed
• B. Encourage the client to drink fluids
• C. Provide the client with a carbohydrate snack
• D. Assess the client for signs of hypoglycemia

Correct answer: A

Rationale: When a client with diabetes mellitus presents with a high blood sugar level of 320 mg/dL, the nurse's initial action should be to administer sliding scale insulin as prescribed. The priority is to bring down the elevated glucose level promptly to prevent further complications. Encouraging the client to drink fluids or providing a carbohydrate snack would not effectively address the elevated blood sugar level in this scenario. Assessing for signs of hypoglycemia is not appropriate as the client's blood sugar level is high, not low.

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