Nursing Elites

1. An elderly male client is admitted to the urology unit with acute renal failure due to a postrenal obstruction. Which question best assists the nurse in obtaining relevant historical data?

• A. Have you had any difficulty starting your urinary stream?
• B. Do you have a history of kidney stones?
• C. How much fluid do you drink daily?
• D. Have you had any previous urinary tract infections?

Correct answer: A

Rationale: The correct answer is A: 'Have you had any difficulty starting your urinary stream?' This question is the most relevant as difficulty starting urination can indicate an obstruction, which aligns with the client's current condition of postrenal obstruction causing acute renal failure. Choice B is incorrect as a history of kidney stones may not be directly related to the current obstruction. Choice C, asking about daily fluid intake, is not specific to the current issue of postrenal obstruction. Choice D inquires about previous urinary tract infections, which are not directly related to the current acute renal failure caused by postrenal obstruction.

2. The nurse weighs a 6-month-old infant during a well-baby check-up and determines that the baby's weight has tripled compared to the birth weight of 7 pounds 8 ounces. The mother asks if the baby is gaining enough weight. What response should the nurse offer?

• A. Your baby is gaining weight right on schedule
• B. What food does your baby usually eat in a normal day?
• C. The baby is below the normal percentile for weight gain
• D. What was the baby's weight at the last well-baby check-up?

Correct answer: A

Rationale: The correct answer is A: 'Your baby is gaining weight right on schedule.' Tripling of birth weight by 6 months is a normal growth pattern in infants, indicating appropriate weight gain and development. Choice B is unrelated to the question as it focuses on the baby's diet rather than addressing the weight gain concern. Choice C is incorrect as tripling the birth weight is considered a healthy growth pattern, not below normal percentile. Choice D is irrelevant to the mother's question about the adequacy of weight gain.

3. An adult male who fell from a roof and fractured his left femur is admitted for surgical stabilization after having a soft cast applied in the emergency department. Which assessment finding warrants immediate intervention by the nurse?

• A. Weak palpable distal pulses
• B. Pain at the fracture site
• C. Mild swelling of the leg
• D. Bruising around the fracture site

Correct answer: A

Rationale: In a patient with a fractured femur, weak palpable distal pulses can indicate compromised circulation to the lower extremity. This finding suggests a potential vascular compromise that requires immediate intervention to prevent further complications like compartment syndrome or ischemia. Pain at the fracture site, mild swelling of the leg, and bruising around the fracture site are expected following such an injury and surgical stabilization, and while they should be monitored, they do not require immediate intervention like addressing compromised circulation.

4. The nurse is caring for a client with chronic heart failure who is receiving furosemide (Lasix). Which laboratory value requires immediate intervention?

• A. Serum potassium of 3.0 mEq/L
• B. Serum sodium of 135 mEq/L
• C. Serum creatinine of 1.8 mg/dL
• D. Blood glucose of 200 mg/dL

Correct answer: A

Rationale: A serum potassium level of 3.0 mEq/L is most concerning in a client receiving furosemide as it indicates hypokalemia, which requires immediate intervention. Hypokalemia can lead to serious cardiac arrhythmias, which can be life-threatening. Serum sodium of 135 mEq/L and serum creatinine of 1.8 mg/dL are within normal ranges and do not require immediate intervention in this case. Blood glucose of 200 mg/dL is elevated but does not pose an immediate threat to the client's life in the context of heart failure and furosemide therapy.

5. The nurse is preparing a community education program on osteoporosis. Which instruction is helpful in preventing bone loss and promoting bone formation?

• A. Recommend weight-bearing physical activity.
• B. Encourage a diet high in dairy products.
• C. Suggest vitamin D supplementation.
• D. Advise avoiding caffeine and alcohol.

Correct answer: A

Rationale: The correct answer is A: Recommend weight-bearing physical activity. Weight-bearing exercises are effective in maintaining bone density and preventing osteoporosis by promoting bone formation. Encouraging a diet high in dairy products (choice B) can provide calcium, but it's not as directly related to bone formation as physical activity. While vitamin D supplementation (choice C) is important for calcium absorption and bone health, it is not directly involved in promoting bone formation. Advising to avoid caffeine and alcohol (choice D) can be beneficial for bone health, but it is not as directly related to promoting bone formation as weight-bearing physical activity.

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