Nursing Elites

1. A client recovering from a cystoscopy is being assessed by a nurse. Which assessment findings should alert the nurse to urgently contact the health care provider? (Select all that apply.)

• A. Decrease in urine output
• B. Blood clots present in the urine
• C. Prescription for metformin
• D. A & B

Correct answer: D

Rationale: After a cystoscopy, the nurse should monitor urine output and promptly contact the provider if there is a decrease or absence of urine output. Additionally, the nurse should assess for blood in the urine. While some pink-tinged urine may be expected, the presence of gross bleeding or blood clots warrants immediate provider notification. Tolerating oral fluids is a positive sign and does not require urgent intervention. Metformin would be a concern if the client received contrast dye, which is not used in a cystoscopy. A burning sensation when urinating is a common post-procedure experience and does not necessitate contacting the provider. Therefore, choices A and B are the correct answers as they indicate potentially serious complications that require immediate attention, while choices C and D do not align with urgent concerns following a cystoscopy.

2. Which of the following is a priority intervention for a patient with suspected sepsis?

• A. Administering antibiotics.
• B. Administering IV fluids.
• C. Administering antipyretics.
• D. Monitoring blood cultures.

Correct answer: D

Rationale: Monitoring blood cultures is a crucial intervention in suspected sepsis because it helps identify the causative organism, which is essential for guiding appropriate antibiotic therapy. Administering antibiotics (Choice A) is important but should be guided by blood culture results. Administering IV fluids (Choice B) is also essential to support hemodynamic stability in sepsis. Administering antipyretics (Choice C) may help reduce fever but is not a priority compared to identifying the causative organism through blood cultures.

3. An elderly client is admitted with a diagnosis of bacterial pneumonia. The nurse's assessment of the client will most likely reveal which sign/symptom?

• A. Leukocytosis and febrile.
• B. Polycythemia and crackles.
• C. Pharyngitis and sputum production.
• D. Confusion and tachycardia.

Correct answer: D

Rationale: The onset of pneumonia in the elderly may be signaled by general deterioration, confusion, increased heart rate or increased respiratory rate due to the decreased oxygen- carbon dioxide exchange at the alveoli, known as the V-Q mismatch.

4. An overweight client taking warfarin (Coumadin) has dry skin due to decreased arterial blood flow. What should the nurse instruct the client to do? Select all that apply.

• A. Apply lanolin or petroleum jelly to intact skin.
• B. Follow a reduced-calorie, reduced-fat diet.
• C. Inspect the involved areas daily for new ulcerations.
• D. Instruct the client to limit activities of daily living (ADLs).

Correct answer: A

Rationale: To address dry skin and prevent chronic ulcers and infections in an overweight client on warfarin with decreased arterial blood flow, the nurse should instruct the client to apply lanolin or petroleum jelly to intact skin. This helps maintain skin integrity and moisture. Following a reduced-calorie, reduced-fat diet (Choice B) may be beneficial for weight management but is not directly related to skin care. Inspecting involved areas daily for new ulcerations (Choice C) is important for skin assessment and early intervention but does not specifically address dry skin. Instructing the client to limit activities of daily living (ADLs) (Choice D) is not necessary for addressing dry skin; in fact, promoting mobility and circulation through appropriate activities is crucial.

5. The charge nurse of the medical-surgical unit is making staff assignments. Which staff member should be assigned to a client with chronic kidney disease who is exhibiting a low-grade fever and a pericardial friction rub?

• A. Registered nurse who just floated from the surgical unit
• B. Registered nurse who just floated from the dialysis unit
• C. Registered nurse who was assigned the same client yesterday
• D. Licensed practical nurse with 5 years of experience on this floor

Correct answer: C

Rationale: The client is exhibiting symptoms of pericarditis, which can occur with chronic kidney disease. Continuity of care is crucial to assess subtle changes in clients' conditions. Therefore, the registered nurse (RN) who previously cared for this client should be assigned again. Float nurses may lack knowledge of the unit and its clients, potentially leading to oversight of critical details. The licensed practical nurse, while experienced, may not possess the advanced assessment skills and education level of an RN to effectively evaluate and manage pericarditis in this client.

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