Nursing Elites

1. A client with overflow incontinence needs assistance with elimination. What intervention should the nurse include in the plan of care?

• A. Stroke the medial aspect of the thigh.
• B. Use intermittent catheterization.
• C. Provide digital anal stimulation.
• D. Use the Valsalva maneuver.

Correct answer: D

Rationale: In clients with overflow incontinence, the voiding reflex arc is impaired. The Valsalva maneuver, which involves holding the breath and bearing down as if to defecate, can help initiate voiding by applying mechanical pressure. Options A and C (stroking the thigh or anal stimulation) rely on an intact reflex arc to trigger elimination and are not effective for clients with overflow incontinence. Intermittent catheterization (Option B) is a last resort due to the high risk of infection and should only be considered if other interventions fail.

2. A client without a history of respiratory disease has a pulse oximeter in place after surgery. The nurse monitors the pulse oximeter readings to ensure that oxygen saturation remains above:

• A. 85%
• B. 89%
• C. 95%
• D. 100%

Correct answer: C

Rationale: Pulse oximetry is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin (SaO2). In the absence of underlying respiratory disease, the expected oxygen saturation level is at least 95%. Oxygen saturation levels below 95% may indicate hypoxemia, which can compromise tissue perfusion and oxygen delivery to vital organs. Therefore, maintaining oxygen saturation above 95% is crucial to ensure adequate oxygenation post-surgery. Choices A, B, and D are incorrect as they represent oxygen saturation levels that are below the expected value for a client without a history of respiratory disease, which should be at least 95%.

3. A female patient will receive doxycycline to treat a sexually transmitted infection (STI). What information will the nurse include when teaching this patient about this medication?

• A. Nausea and vomiting are uncommon adverse effects.
• B. The drug may cause possible teratogenic effects.
• C. Increase intake of dairy products with each dose of this medication.
• D. Use a backup method of contraception if taking oral contraceptives.

Correct answer: D

Rationale: The correct answer is D. The desired action of oral contraceptives can be reduced when taken with tetracyclines like doxycycline. Therefore, patients on oral contraceptives should be advised to use a backup contraception method while taking doxycycline. Choice A is incorrect because nausea and vomiting are common adverse effects of doxycycline. Choice B is incorrect because doxycycline is not known for causing teratogenic effects. Choice C is incorrect because dairy products can interfere with the absorption of doxycycline, so they should be avoided when taking this medication.

4. An emergency department nurse assesses a client with a history of urinary incontinence who presents with extreme dry mouth, constipation, and an inability to void. Which question should the nurse ask first?

• A. Are you drinking plenty of water?
• B. What medications are you taking?
• C. Have you tried laxatives or enemas?
• D. Has this type of thing ever happened before?

Correct answer: B

Rationale: In this scenario, the client's symptoms of dry mouth, constipation, and inability to void are indicative of anticholinergic side effects, which can be caused by medications like propantheline (Pro-Banthine) commonly used to treat incontinence. The first question the nurse should ask is about the client's medications to determine if they are taking anticholinergic drugs. This information is crucial as it can help differentiate between a simple side effect or a potential overdose. Asking about water intake (Choice A) may be relevant later but is not the priority in this situation. Questioning about laxatives or enemas (Choice C) and past occurrences (Choice D) are not as pertinent initially as identifying the client's current medication status.

5. Which of the following is a primary intervention for a patient with sepsis?

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

Correct answer: D

Rationale: Monitoring blood cultures is a primary intervention for a patient with sepsis because it helps identify the causative organism, which is crucial in guiding appropriate antibiotic therapy. Administering antibiotics (Choice A) is important in treating sepsis but is considered a secondary intervention. Administering IV fluids (Choice B) is also crucial for sepsis management to restore perfusion and hemodynamic stability. Administering antipyretics (Choice C) may help reduce fever, but it is not a primary intervention for managing sepsis.

Similar Questions