Nursing Elites

1. A client with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse include in the client's postoperative discharge instructions?

• A. Report when hematuria becomes pink-tinged
• B. Use incentive spirometer
• C. Restrict physical activities
• D. Monitor urinary stream for a decrease in output

Correct answer: D

Rationale: After lithotripsy, monitoring the urinary stream for a decrease in output is essential to identify any potential complications such as urinary retention or obstruction. Reporting pink-tinged hematuria is important, but monitoring the urinary stream for a decrease in output takes precedence as it directly assesses renal function and potential complications. Using an incentive spirometer is not directly related to post-lithotripsy care. Restricting physical activities may be necessary initially but is not the priority compared to monitoring urinary output.

2. An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her fingers. After warming her hands, the fingers turn red, and the client reports a burning sensation. What action should the nurse take?

• A. Apply a cool compress to the affected fingers for 20 minutes
• B. Secure a pulse oximeter to monitor the client's oxygen saturation
• C. Report the finding to the healthcare provider as soon as possible
• D. Continue to monitor the fingers until the color returns to normal

Correct answer: D

Rationale: In primary Raynaud phenomenon, the fingers go through a color sequence of pallor, cyanosis, and then redness when warmed. The burning sensation reported by the client indicates reperfusion. Continuing to monitor the fingers until the color returns to normal is appropriate in this situation as it ensures that the symptoms are resolving without the need for further intervention. Applying a cool compress could exacerbate the symptoms by causing vasoconstriction. Securing a pulse oximeter to monitor oxygen saturation is not necessary in this case as the issue is related to vasospasm rather than oxygenation. Reporting the finding to the healthcare provider is not urgent unless there are signs of complications or the symptoms do not improve with warming.

3. What are priority nursing interventions designed to do for a 4-year-old child with cerebral palsy?

• A. Assist with referral to specialized education.
• B. Support the child with independent toileting.
• C. Assist the child to develop effective communication.
• D. Encourage the child to ambulate independently.

Correct answer: C

Rationale: The correct answer is C: 'Assist the child to develop effective communication.' Children with cerebral palsy often face challenges with communication skills. Therefore, priority nursing interventions aim to help them improve their communication abilities. Choice A is incorrect because while education is important, the priority for a child with cerebral palsy is to address immediate needs. Choice B is incorrect as toileting, although important, is not the priority in this case. Choice D is incorrect as ambulation may not be feasible or the most critical concern for a child with cerebral palsy.

4. A 2-year-old child with laryngotracheobronchitis (LTB) is fussy and restless in the oxygen tent. The oxygen level in the tent is 25%, and blood gases are normal. What would be the correct action by the nurse?

• A. Restrain the child in the tent and notify the health care provider.
• B. Increase the oxygen concentration in the tent.
• C. Take the child out of the tent and into the playroom.
• D. Ask the mother for help in comforting the child.

Correct answer: B

Rationale: The child with LTB should be placed in the mist tent with 30% oxygen. Restlessness is caused by poor oxygenation. The child should not be taken out of the oxygenated tent. While the mother could be asked to help comfort the child, and the health care provider may be notified, the priority is to set the oxygen at the correct level.

5. An adult client is admitted with AIDS and oral candidiasis manifested by several painful mouth ulcers. The nurse delegates oral care to the unlicensed assistive personnel (UAP) and discusses how to assist the client. Which instruction should the nurse provide the UAP?

• A. Assist with personal care, but leave oral care for the nurse to complete.
• B. Provide a soft bristle brush for the client to use during oral care.
• C. Use alcohol-based mouthwash to clean the ulcers.
• D. Apply an antifungal cream to the mouth ulcers.

Correct answer: B

Rationale: The correct answer is B: 'Provide a soft bristle brush for the client to use during oral care.' Providing a soft bristle brush helps reduce trauma to the oral mucosa and assists in oral care. Choice A is incorrect because oral care can be safely delegated to UAPs. Choice C is wrong as alcohol-based mouthwash can further irritate the ulcers. Choice D is incorrect as applying an antifungal cream directly to the mouth ulcers is not the standard treatment for oral candidiasis.

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