Nursing Elites

1. When bathing an uncircumcised boy older than 3 years, which action should the nurse take?

• A. Remind the child to clean his genital area.
• B. Defer perineal care due to the child's age.
• C. Retract the foreskin gently to cleanse the penis.
• D. Inquire about the reason for the child not being circumcised.

Correct answer: C

Rationale: The correct action when bathing an uncircumcised boy older than 3 years is to gently retract the foreskin to cleanse the penis. This is important to ensure proper hygiene and prevent the accumulation of bacteria that can lead to infections. It is not advisable to defer perineal care because of the child's age, as hygiene is crucial at any age. Asking the parents about the circumcision status may not be relevant during routine perineal care. Reminding the child to clean his genital area is not as effective as directly cleaning the area during bathing.

2. What action should the nurse implement to prepare a client for the potential side effects of a newly prescribed medication?

• A. Assess the client for health alterations that may be impacted by the effects of the medication
• B. Teach the client how to administer the medication to promote the best absorption
• C. Administer a half dose and observe the client for side effects before administering a full dosage
• D. Encourage the client to drink plenty of fluids to promote effective drug distribution

Correct answer: A

Rationale: Before initiating a new medication, the nurse should conduct a thorough assessment of the client to identify any pre-existing health conditions or risk factors that could be affected by the medication. This assessment helps in establishing a baseline for monitoring potential side effects and determining the medication's appropriateness for the client. Choice B is incorrect as teaching the client how to administer the medication does not directly address preparing for potential side effects. Choice C is incorrect because administering a half dose without a proper assessment could be unsafe. Choice D is incorrect as encouraging fluid intake is not directly related to preparing for potential side effects of a medication.

3. The client with cholecystitis is being instructed on dietary choices. Which meal best meets the dietary needs of this client?

• A. Steak, baked beans, and a salad
• B. Broiled fish, green beans, and an apple
• C. Pork chops, macaroni and cheese, and grapes
• D. Avocado salad, milk, and angel food cake

Correct answer: B

Rationale: Cholecystitis requires a low-fat diet to reduce stress on the gallbladder. The meal of broiled fish, green beans, and an apple aligns with this dietary recommendation by providing lean protein and low-fat, high-fiber foods that are easier for the body to digest, making it the most suitable choice for a client with cholecystitis.

4. A client is receiving total parenteral nutrition (TPN). Which assessment finding is most concerning to the nurse?

• A. Blood glucose level of 150 mg/dL.
• B. Blood pressure of 110/70 mm Hg.
• C. Serum albumin level of 3.5 g/dL.
• D. The client's temperature is 100.4°F (38°C).

Correct answer: D

Rationale: A temperature of 100.4°F (38°C) (D) is the most concerning finding for a client receiving total parenteral nutrition (TPN) as it may indicate an infection, which poses a significant risk. Monitoring blood glucose level (A), blood pressure (B), and serum albumin (C) are also important, but an elevated temperature suggests a potential serious complication that requires immediate attention.

5. When assisting an older client who can stand but not ambulate from the bed to a chair, what is the best action for the nurse to implement?

• A. Use a mechanical lift to transfer the client from the bed to a chair.
• B. Place a roller board under the client who is sitting on the side of the bed and slide the client to the chair.
• C. Lift the client out of bed to the chair with another staff member using a coordinated effort on the count of three.
• D. Place a transfer belt around the client, assist the client to stand, and pivot to a chair that is placed at a right angle to the bed.

Correct answer: D

Rationale: The best action for the nurse when assisting an older client who can stand but not ambulate from the bed to a chair is to use a transfer belt. Placing a transfer belt around the client, assisting the client to stand, and pivoting to a chair that is placed at a right angle to the bed allows for a safe and controlled transfer. This method promotes patient independence while ensuring safety during the transfer process. Choices A, B, and C are incorrect because using a mechanical lift may not be necessary for a client who can stand, using a roller board may not provide enough stability, and lifting the client with the help of another staff member may not be the safest option for the client's independence and safety.

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