Nursing Elites

1. A client with functional urinary incontinence is being taught by a nurse. Which statement should the nurse include in this client’s teaching?

• A. Clean around your catheter daily with soap and water.
• B. Wash the vaginal weights with a 10% bleach solution after each use.
• C. Informing about available operations to repair your bladder.
• D. Buy slacks with elastic waistbands that are easy to pull down.

Correct answer: D

Rationale: Functional urinary incontinence is not related to bladder issues but rather to difficulties with ambulation or accessing the toilet. The goal is to help the client manage clothing independently. Elastic waistband slacks that are easy to pull down facilitate timely access to the toilet. Choices A and B are unrelated and not applicable to functional urinary incontinence. Choice C is incorrect as surgeries to repair the bladder are not indicated for functional urinary incontinence.

2. A client with peripheral arterial disease (PAD) has cool and pale feet with diminished pulses. Which of the following interventions should the nurse implement?

• A. Keep the legs elevated above the level of the heart.
• B. Encourage the client to exercise daily.
• C. Apply warm compresses to the affected area.
• D. Apply ice packs to the affected area.

Correct answer: C

Rationale: In peripheral arterial disease (PAD), there is decreased blood flow to the extremities. Applying warm compresses helps dilate blood vessels, improve circulation, and relieve symptoms. Elevating the legs above the heart level may further compromise blood flow. Encouraging daily exercise is important in PAD management but may not be appropriate when the client has cool, pale feet with diminished pulses. Applying ice packs can worsen vasoconstriction and further reduce blood flow, exacerbating symptoms in PAD.

3. A nursing student is suctioning a client through a tracheostomy tube while a nurse observes. Which action by the student would prompt the nurse to intervene and demonstrate the correct procedure? Select all that apply.

• A. Setting the suction pressure to 60 mm Hg
• B. Applying suction throughout the procedure
• C. Assessing breath sounds before suctioning
• D. Placing the client in a supine position before the procedure

Correct answer: A

Rationale: The correct suction pressure for an adult client with a tracheostomy tube is typically between 80 to 120 mm Hg. Suction should be applied intermittently during catheter withdrawal to avoid damaging the airway. Assessing breath sounds before suctioning is important to ensure the procedure is necessary. Placing the client in a supine position before suctioning can compromise their airway; instead, the head of the bed should be elevated to facilitate proper drainage and reduce the risk of aspiration. Therefore, setting the suction pressure to 60 mm Hg is incorrect and would prompt the nurse to intervene and correct the procedure.

4. The client is being educated by the nurse on home blood glucose monitoring. Which of the following blood glucose measurements indicates hypoglycemia?

• A. 59 mg/dL (3.3 mmol/L)
• B. 75 mg/dL (4.2 mmol/L)
• C. 108 mg/dL (6 mmol/L)
• D. 119 mg/dL (6.6 mmol/L)

Correct answer: A

Rationale: A blood glucose level of 59 mg/dL (3.3 mmol/L) is considered hypoglycemia, which is an abnormally low blood sugar level. This level requires immediate attention as it can lead to symptoms such as confusion, shakiness, and even loss of consciousness if left untreated. Choices B, C, and D have blood glucose levels within the normal range or slightly higher, indicating euglycemia or normal blood sugar levels, and not hypoglycemia.

5. A patient presents with severe chest pain radiating to the left arm. Which of the following diagnostic tests is the priority?

• A. Complete blood count (CBC)
• B. Electrocardiogram (ECG)
• C. Chest X-ray
• D. Serum electrolytes

Correct answer: B

Rationale: In a patient presenting with severe chest pain radiating to the left arm, the priority diagnostic test is an Electrocardiogram (ECG) to assess for myocardial infarction. An ECG can quickly identify changes indicative of ischemia or infarction, guiding prompt management. A Complete Blood Count (CBC) may provide some information but is not the primary test for evaluating chest pain related to myocardial infarction. A Chest X-ray can be useful in assessing lung pathologies or certain cardiac conditions; however, it does not provide immediate information on myocardial infarction, making it a secondary option in this scenario. Serum electrolytes may become important in later stages but do not offer immediate insights into myocardial infarction. Therefore, they are a lower priority compared to obtaining an ECG for timely diagnosis and intervention.

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