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. When preparing a client who has had a total laryngectomy for discharge, what instruction is most important for the nurse to include in the discharge teaching?

• A. Recommend that the client carry suction equipment at all times.
• B. Instruct the client to have writing materials with them at all times.
• C. Tell the client to carry a medic alert card stating that they are a total neck breather.
• D. Tell the client not to travel alone.

Correct answer: C

Rationale: The most crucial instruction for a client who has had a total laryngectomy is to carry a medic alert card stating that they are a total neck breather. This is important because if they experience a cardiac arrest, mouth-to-neck breathing may be required. Choice A about carrying suction equipment is not the most critical as the client may not always need it. Choice B is not as essential as having a medic alert card. Choice D is not directly related to the client's safety due to their laryngectomy.

3. The client is scheduled to begin continuous ambulatory peritoneal dialysis (CAPD). Which of the following statements by the client indicates that more teaching is required?

• A. I will need to limit my intake of protein.
• B. I can skip a dialysis session if I feel tired.
• C. I should increase my intake of potassium-rich foods.
• D. I can eat whatever I want, as long as I take my medications.

Correct answer: B

Rationale: The correct answer is B. Skipping a dialysis session can lead to serious complications as it disrupts the treatment schedule and can result in the accumulation of waste products and fluid in the body. The client must understand the importance of adhering to the prescribed dialysis regimen to maintain optimal health. Choices A, C, and D are incorrect because limiting protein intake, increasing potassium-rich foods, and taking medications do not pose the same risk as skipping dialysis sessions. These aspects are important in the management of peritoneal dialysis but do not outweigh the critical need for regular dialysis sessions to prevent complications.

4. A client with chronic kidney disease (CKD) is experiencing nausea, vomiting, visual changes, and anorexia. Which action by the nurse is best?

• A. Check the client’s digoxin (Lanoxin) level.
• B. Administer an anti-nausea medication.
• C. Ask if the client can eat crackers.
• D. Refer the client to a gastrointestinal specialist.

Correct answer: A

Rationale: In a client with chronic kidney disease experiencing symptoms like nausea, vomiting, visual changes, and anorexia, it is crucial for the nurse to suspect digoxin (Lanoxin) toxicity. These symptoms are indicative of digoxin toxicity. Therefore, the best action for the nurse to take is to check the client's digoxin level. Administering anti-nausea medication, asking about eating crackers, and referring to a gastrointestinal specialist may help with symptom management but do not address the underlying cause of the symptoms, which is digoxin toxicity in this case.

5. A client admitted from a nursing home after several recent falls needs a urine sample for culture and sensitivity. What should the nurse complete first?

• A. Obtain urine sample for culture and sensitivity.
• B. Administer intravenous antibiotics.
• C. Encourage protein intake and additional fluids.
• D. Consult physical therapy for gait training.

Correct answer: A

Rationale: In this scenario, the priority intervention is to obtain a urine sample for culture and sensitivity. Older adults with recent falls may have atypical symptoms of urinary tract infection (UTI), which can present as new-onset confusion or falling. It is crucial to rule out UTI before initiating antibiotics. While administering antibiotics, encouraging protein intake, fluids, and consulting physical therapy are important interventions, they should follow the urine sample collection to ensure accurate diagnosis and appropriate treatment.

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