Nursing Elites

1. During the admission interview, which question should the nurse ask the male client diagnosed with aorto-iliac disease?

• A. “Do you have trouble sitting for long periods of time?”
• B. “How often do you have a bowel movement and urinate?”
• C. “When you lie down do you feel throbbing in your abdomen?”
• D. “Have you experienced any problems having sexual intercourse?”

Correct answer: D

Rationale: The correct question for the nurse to ask the male client diagnosed with aorto-iliac disease during the admission interview is about any problems experienced during sexual intercourse. Aorto-iliac disease can lead to impaired blood flow to the pelvis and lower extremities, affecting sexual function. Therefore, it is essential to assess the client's sexual health in such cases. The other options, such as sitting for long periods of time, bowel movements and urination frequency, and throbbing sensation when lying down, are not directly related to the potential impact of aorto-iliac disease on sexual function. Hence, they are not the most pertinent questions to ask during the admission interview.

2. What is the best position for any procedure that involves vaginal and cervical examination?

• A. Dorsal recumbent
• B. Side lying
• C. Supine
• D. Lithotomy

Correct answer: D

Rationale: The lithotomy position is the most suitable position for procedures involving vaginal and cervical examination because it provides the best access to the vaginal and cervical regions. In this position, the patient lies on their back with their legs flexed and feet placed in stirrups, allowing for optimal visualization and access to the area. This position facilitates proper examination, diagnosis, and treatment when working in the gynecological field. Choices A, B, and C are incorrect as they do not provide the necessary exposure and access required for a thorough vaginal and cervical examination. Dorsal recumbent, side lying, and supine positions may limit visibility and hinder the examination process in such cases.

3. The nurse is analyzing laboratory values for the assigned clients. Which finding, based on the client's medical history, indicates the need for immediate follow-up?

• A. Client with chronic kidney disease and serum creatinine of 1.6 mg/dL
• B. Client with diabetes mellitus and a glycosylated hemoglobin A1c (HbA1c) of 7.0%
• C. Client with heart failure and a B-type natriuretic peptide (BNP) of 140 pg/mL
• D. Client who is male and has anemia with hemoglobin of 16.5 g/dL and hematocrit of 45%

Correct answer: B

Rationale: An HbA1c of 7.0% in a client with diabetes mellitus indicates poor long-term glucose control, necessitating immediate follow-up. Choice A, chronic kidney disease with a serum creatinine of 1.6 mg/dL, though concerning, does not indicate an immediate need for follow-up. Choice C, heart failure with a BNP of 140 pg/mL, may require monitoring but not immediate follow-up. Choice D, a male client with anemia and normal hemoglobin and hematocrit levels, does not warrant immediate attention based on the provided information.

4. The client has failed to conceive after many attempts over a three-year time period and asks the nurse, “I have tried everything. What should I do now?” Which statement is the nurse’s best response?

• A. Assess the intravenous fluids for rate and volume
• B. Change the surgical dressing every day at the same time
• C. Monitor the client’s medication levels daily
• D. Monitor the percentage of each meal eaten

Correct answer: A

Rationale: The nurse's best response should focus on providing empathetic support and guiding the client to explore further options, such as fertility specialists or treatments. Assessing intravenous fluids for rate and volume is not relevant to the client's concern about infertility. Changing surgical dressing, monitoring medication levels, and tracking meal intake are all unrelated to the client's fertility issues.

5. The nurse is caring for the client one (1) day postoperative sigmoid colostomy operation. Which independent nursing intervention should the nurse implement?

• A. Change the infusion rate of the intravenous fluid
• B. Encourage the client to discuss his or her feelings
• C. Administer opioid narcotic medications for pain management
• D. Assist the client out of bed to sit in the chair twice daily

Correct answer: D

Rationale: Assisting the client to sit in a chair is a crucial nursing intervention postoperatively. It helps prevent complications such as thrombosis, pneumonia, and pressure ulcers by promoting circulation and aiding in recovery. Changing the infusion rate of the intravenous fluid would require a physician's order and is not within the nurse's independent scope of practice. Encouraging the client to discuss feelings and administering medications for pain management are important interventions but may not be as immediately necessary as assisting the client in mobilizing early postoperatively.

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