Nursing Elites

1. The nurse in the pediatric clinic performs a physical assessment of a 13-year-old boy. Which of the following findings by the nurse requires immediate intervention?

• A. The adolescent complains of his scrotum aching after exercise. The nurse palpates a worm-like mass above the testes.
• B. The nurse noted unilateral breast enlargement.
• C. The child’s scrotum appears swollen, and a soft mass is palpated. The nurse is unable to insert a finger above the mass.
• D. The child’s scrotum appears enlarged and red. The nurse palpated a thickened and swollen spermatic cord.

Correct answer: D

Rationale: Choice D is the correct answer because a swollen and thickened spermatic cord could indicate testicular torsion, which is a surgical emergency. Testicular torsion occurs when the spermatic cord twists, cutting off the blood supply to the testicle. This condition requires immediate intervention to prevent testicular damage. Choices A, B, and C do not present findings that suggest a surgical emergency requiring immediate intervention.

2. The nurse is preparing a postoperative nursing care plan for the client recovering from a hemorrhoidectomy. Which intervention should the nurse implement?

• A. Establish a rapport with the client to decrease embarrassment during site assessment
• B. Encourage the client to lie in the lithotomy position twice a day
• C. Milk the tube inserted during surgery to facilitate the passage of flatus
• D. Digitally dilate the rectal sphincter to express old blood

Correct answer: A

Rationale: Establishing rapport with the client is crucial in postoperative care to create a trusting relationship, reduce embarrassment, and enhance comfort during assessments. Encouraging the client to lie in the lithotomy position is not recommended after a hemorrhoidectomy as it can be uncomfortable and may disrupt wound healing. Milking the tube inserted during surgery is not a standard practice and could lead to complications. Digitally dilating the rectal sphincter is not indicated post-hemorrhoidectomy and can cause harm to the client.

3. For which client situation would a consultation with a rapid response team (RRT) be most appropriate?

• A. 45-year-old; 2 years post kidney transplant; second hospital day for treatment of pneumonia; no urine output for 6 hours; temperature 101.4°F; heart rate of 98 beats per minute; respirations 20 breaths per minute; blood pressure 88/72 mm Hg; is restless
• B. 72-year-old; 24 hours after removal of a chest tube that was used to drain pleural fluid (effusion); temperature 97.8°F; heart rate 92 beats per minute; respirations 28 breaths per minute; blood pressure 132/86 mm Hg; anxious about going home
• C. 56-year-old fourth hospital day after a coronary artery bypass procedure; sore chest; pain with walking temperature 97°F; heart rate 84 beats per minute; respirations 22 breaths per minute; blood pressure 87/72 mm Hg; bored with hospitalization.
• D. 86-year-old; 48 hours postoperative repair of a fractured hip (nail inserted; alert; oriented; using patient-controlled analgesia (PCA) pump; temperature 96.8°F; heart rate 60 beats per minute; respirations 16 breaths per minute; blood pressure 90/62 mm Hg; talking with daughter.

Correct answer: A

Rationale: A consultation with a Rapid Response Team (RRT) is most appropriate for the 45-year-old client described in Choice A. This client is 2 years post kidney transplant, presenting with no urine output for 6 hours, a temperature of 101.4°F, heart rate of 98 beats per minute, respirations of 20 breaths per minute, and a blood pressure of 88/72 mm Hg, along with restlessness. These clinical signs are indicative of possible acute renal failure and sepsis, requiring immediate intervention by the rapid response team. Choices B, C, and D do not present the same level of urgency and severity of symptoms as the client in Choice A, making them less appropriate for consultation with the RRT.

4. A client takes an antidepressant and oral contraceptives. Which herbal supplement should the nurse educate the client about as a potential drug-herb interaction?

• A. Iron supplement
• B. Garlic
• C. Green tea
• D. St. John’s Wort

Correct answer: D

Rationale: St. John’s Wort is the correct answer because it can interact with antidepressants and oral contraceptives, potentially affecting their efficacy. Iron supplement, garlic, and green tea do not typically interact with antidepressants or oral contraceptives to the same extent as St. John’s Wort.

5. The HCP orders cultures of the urethral urine, bladder urine, and prostatic fluid. Which instructions would the nurse teach to achieve the first two (2) specimens?

• A. Collect the first 15 mL in one jar and then the next 50 mL in another
• B. Collect three (3) early morning, clean voided urine specimens
• C. Collect the specimens after the HCP massages the prostate
• D. Collect a routine urine specimen for analysis

Correct answer: A

Rationale: The correct answer is to collect the first 15 mL in one jar and then the next 50 mL in another. This method allows for accurate cultures of urethral and bladder urine. Choice B is incorrect because it does not specify the correct method for collecting urethral and bladder urine separately. Choice C is incorrect because prostatic fluid is a separate specimen that does not require prostatic massage for collection. Choice D is incorrect as it suggests collecting a routine urine specimen, which does not fulfill the HCP's orders for specific cultures.

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