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. The nurse is caring for a client who is postoperative for a femoral head fracture repair. Which intervention(s) should the nurse plan to administer for deep vein thrombosis prophylaxis?

• A. Pneumatic compression devices
• B. Incentive spirometry
• C. Assisted ambulation
• D. Calf-pump exercises

Correct answer: A

Rationale: The correct intervention for deep vein thrombosis prophylaxis in a postoperative client with a femoral head fracture repair is the use of pneumatic compression devices. These devices help prevent stasis in the lower extremities by promoting venous return through intermittent compression. Incentive spirometry is used to prevent respiratory complications by promoting lung expansion and clearing secretions, not for DVT prophylaxis. Assisted ambulation and calf-pump exercises are beneficial for promoting circulation and preventing DVT, but pneumatic compression devices are more effective in this specific postoperative scenario.

3. A client with chronic renal failure is being treated with sodium polystyrene sulfonate (Kayexalate). The nurse should monitor the client for which of the following?

• A. Hyponatremia.
• B. Hypokalemia.
• C. Hyperkalemia.
• D. Hypocalcemia.

Correct answer: C

Rationale: The correct answer is C: Hyperkalemia. Sodium polystyrene sulfonate (Kayexalate) is used to treat high potassium levels (hyperkalemia) by exchanging sodium ions for potassium ions in the large intestine, which is then eliminated through the feces. Therefore, the nurse should monitor the client for changes in potassium levels to ensure the effectiveness of the treatment. Choices A, B, and D are incorrect because sodium polystyrene sulfonate (Kayexalate) is not associated with causing hyponatremia, hypokalemia, or hypocalcemia.

4. The patient is receiving acetazolamide (Diamox) for metabolic alkalosis and fluid overload. After taking the medication, the patient complains of right-sided flank pain. The nurse suspects that the patient has developed which condition?

• A. Gout
• B. Hemolytic anemia
• C. Metabolic acidosis
• D. Renal calculi

Correct answer: D

Rationale: The correct answer is D: Renal calculi. Acetazolamide, a carbonic anhydrase inhibitor, can lead to electrolyte imbalances and the formation of renal calculi. Right-sided flank pain is a classic symptom of renal calculi. Choices A, B, and C are incorrect. Gout is not typically associated with acetazolamide use. Hemolytic anemia and metabolic acidosis are not commonly linked to acetazolamide-induced side effects. Therefore, the patient's symptoms align more closely with the development of renal calculi.

5. Which client should the nurse recognize as most likely to experience sleep apnea?

• A. Middle-aged female who takes a diuretic nightly.
• B. Obese older male client with a short, thick neck.
• C. Adolescent female with a history of tonsillectomy.
• D. School-aged male with a history of hyperactivity disorder.

Correct answer: B

Rationale: The correct answer is B. Sleep apnea is characterized by pauses in breathing during sleep, often due to a collapsed or blocked airway. Obesity and having a short, thick neck are risk factors for sleep apnea because excess fat around the neck can obstruct the airway. Option A (middle-aged female who takes a diuretic nightly) does not present as a common risk factor for sleep apnea. Option C (adolescent female with a history of tonsillectomy) may have had tonsils removed, which could reduce the risk of sleep apnea. Option D (school-aged male with a history of hyperactivity disorder) is not directly associated with an increased risk of sleep apnea.

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