Nursing Elites

1. The nurse is providing discharge instructions to a client who is receiving prednisone 5 mg PO daily for a rash due to contact with poison ivy. Which symptoms should the nurse tell the client to report to the healthcare provider?

• A. Rapid weight gain
• B. Abdominal striae
• C. Moon faces
• D. Gastric irritation

Correct answer: A

Rationale: Rapid weight gain can indicate fluid retention, which is a serious side effect of prednisone and should be reported.

2. A client recovering from a cystoscopy is being assessed by a nurse. Which assessment findings should alert the nurse to urgently contact the health care provider? (Select all that apply.)

• A. Decrease in urine output
• B. Blood clots present in the urine
• C. Prescription for metformin
• D. A & B

Correct answer: D

Rationale: After a cystoscopy, the nurse should monitor urine output and promptly contact the provider if there is a decrease or absence of urine output. Additionally, the nurse should assess for blood in the urine. While some pink-tinged urine may be expected, the presence of gross bleeding or blood clots warrants immediate provider notification. Tolerating oral fluids is a positive sign and does not require urgent intervention. Metformin would be a concern if the client received contrast dye, which is not used in a cystoscopy. A burning sensation when urinating is a common post-procedure experience and does not necessitate contacting the provider. Therefore, choices A and B are the correct answers as they indicate potentially serious complications that require immediate attention, while choices C and D do not align with urgent concerns following a cystoscopy.

3. 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.

4. A client with bladder cancer who underwent a complete cystectomy with ileal conduit is being assessed by a nurse. Which assessment finding should prompt the nurse to urgently contact the healthcare provider?

• A. The ileostomy is draining blood-tinged urine.
• B. There is serous sanguineous drainage on the surgical dressing.
• C. The ileostomy stoma appears pale and cyanotic.
• D. Oxygen saturations are 92% on room air.

Correct answer: C

Rationale: A pale or cyanotic appearance of the ileostomy stoma indicates compromised circulation, which can lead to necrosis if not promptly addressed. On the other hand, blood-tinged urine and serous sanguineous drainage are common following a complete cystectomy with ileal conduit. These findings do not typically indicate an urgent issue. An oxygen saturation of 92% on room air is slightly below the normal range but does not warrant urgent healthcare provider contact unless accompanied by significant respiratory distress or other concerning symptoms.

5. A female client taking oral contraceptives reports to the nurse that she is experiencing calf pain. What action should the nurse implement?

• A. Determine if the client has also experienced breast tenderness and weight gain.
• B. Encourage the client to begin a regular, daily program of walking and exercise.
• C. Advise the client to notify the healthcare provider for immediate medical attention.
• D. Tell the client to stop taking the medication for a week to see if symptoms subside.

Correct answer: C

Rationale: Calf pain is indicative of thrombophlebitis, a serious, life-threatening complication associated with the use of oral contraceptives which requires further assessment and possibly immediate medical intervention.

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