Nursing Elites

1. A client is being discharged following a cystectomy and urinary diversion. What is the most important instruction for the nurse to provide?

• A. Avoid lifting heavy objects for six weeks.
• B. Report any signs of cloudy urine output.
• C. Drink 8 glasses of water a day.
• D. Monitor for signs of infection at the surgical site.

Correct answer: B

Rationale: The most important instruction for the nurse to provide to a client following a cystectomy and urinary diversion is to report any signs of cloudy urine output. Cloudy urine may indicate infection, which is a serious concern in clients with a urinary diversion. Instructing the client to report any signs of infection immediately is crucial to prevent complications. Avoiding heavy lifting is important for postoperative recovery but not as critical as identifying a potential infection. Drinking an adequate amount of water is generally beneficial for health but not the most crucial instruction in this scenario. While monitoring for signs of infection at the surgical site is essential, cloudy urine is a more specific and immediate indicator of a potential problem in clients with urinary diversions.

2. A client reports dizziness when standing up quickly. What advice should the nurse give?

• A. Encourage the client to drink more fluids.
• B. Change positions slowly to prevent dizziness.
• C. Report the symptom to the healthcare provider immediately.
• D. Limit physical activity to avoid triggering dizziness.

Correct answer: B

Rationale: The correct advice for a client experiencing dizziness when standing up quickly is to change positions slowly to prevent dizziness. This symptom is suggestive of postural hypotension, where a sudden change in position can lead to a drop in blood pressure, causing dizziness. Encouraging the client to drink more fluids (Choice A) may be beneficial for other conditions but is not directly related to the prevention of dizziness in this case. Reporting the symptom to the healthcare provider immediately (Choice C) is important if the dizziness is persistent or severe, but the immediate action to prevent it is to change positions slowly. Limiting physical activity (Choice D) may not necessarily address the underlying cause of dizziness in this context.

3. The nurse is preparing to administer a subcutaneous injection to a thin, elderly client. What is the most appropriate site for the injection?

• A. Dorsal aspect of the upper arm.
• B. Upper outer thigh.
• C. Lower abdomen.
• D. Lateral aspect of the upper arm.

Correct answer: B

Rationale: The correct answer is the upper outer thigh. In thin, elderly clients, the upper outer thigh is a recommended site for subcutaneous injections due to the presence of adequate subcutaneous tissue and muscle mass. The dorsal aspect of the upper arm may not provide enough subcutaneous tissue for proper absorption of the medication. The lower abdomen is not ideal for thin individuals as it may lead to injection into muscle rather than subcutaneous tissue. The lateral aspect of the upper arm is also not a commonly recommended site for subcutaneous injections.

4. A client has burns covering 40% of their total body surface area (TBSA). What is the nurse’s priority action?

• A. Monitor the client's urinary output hourly.
• B. Apply cool, moist dressings to the burned areas.
• C. Administer pain medication to reduce discomfort.
• D. Administer IV fluids to prevent hypovolemia.

Correct answer: A

Rationale: The correct answer is A: Monitor the client's urinary output hourly. Clients with burns covering a large percentage of their total body surface area are at high risk for hypovolemia due to fluid loss. Monitoring urinary output is crucial because it helps assess kidney function and fluid balance, providing essential information about the client's hemodynamic status. Applying cool, moist dressings (choice B) is important but not the priority over assessing fluid balance. Administering pain medication (choice C) is essential for comfort but not the priority over monitoring for potential complications like hypovolemia. Administering IV fluids (choice D) is important to prevent hypovolemia, but monitoring urinary output should be the priority to guide fluid resuscitation.

5. A client is admitted with a suspected bowel obstruction. What assessment finding should the nurse report immediately?

• A. Absent bowel sounds in all quadrants.
• B. Distended abdomen with a firm, rigid feel.
• C. Frequent episodes of nausea and vomiting.
• D. Hyperactive bowel sounds and abdominal cramping.

Correct answer: B

Rationale: A distended abdomen with a firm, rigid feel is a concerning sign that suggests a complication such as bowel perforation, which requires immediate intervention. Absent bowel sounds can be expected in bowel obstructions but are not as urgent as a rigid abdomen. Frequent episodes of nausea and vomiting are common with bowel obstructions but do not indicate an immediate life-threatening complication. Hyperactive bowel sounds and abdominal cramping are more indicative of bowel obstruction rather than a complication requiring immediate attention.

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