Nursing Elites

1. The nurse is caring for a patient who has recurrent urinary tract infections. The patient’s current infection is not responding to an antibiotic that has been used successfully several times in the past. The nurse understands that this is most likely due to

• A. acquired bacterial resistance.
• B. cross-resistance.
• C. inherent bacterial resistance.
• D. transferred resistance.

Correct answer: A

Rationale: The correct answer is A: acquired bacterial resistance. Acquired resistance happens when an organism has been exposed to the antibacterial drug, making it less effective over time. Cross-resistance (B) occurs when resistance to one drug leads to resistance to another. Inherent resistance (C) happens without prior exposure to the drug, meaning the bacteria are naturally resistant. Transferred resistance (D) involves the transfer of resistant genes from one organism to another, contributing to resistance development.

2. 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.

3. A nurse cares for a client with urinary incontinence. The client states, “I am so embarrassed. My bladder leaks like a young child’s bladder.” How should the nurse respond?

• A. I understand how you feel. I would be mortified.
• B. Incontinence pads will minimize leaks in public.
• C. I can teach you strategies to help control your incontinence.
• D. More women experience incontinence than you might think.

Correct answer: C

Rationale: The nurse should accept and acknowledge the client’s concerns, and assist the client to learn techniques that will allow control of urinary incontinence. The nurse should not diminish the client’s concerns with the use of pads or stating statistics about the occurrence of incontinence.

4. Which of the following is a common sign of meningitis?

• A. Joint pain.
• B. Severe headache.
• C. Stiff neck.
• D. Coughing up blood.

Correct answer: C

Rationale: A stiff neck is a common sign of meningitis due to inflammation of the meninges. Meningitis typically presents with symptoms such as fever, severe headache, nausea, vomiting, sensitivity to light, and a stiff neck. Joint pain (Choice A) is not a typical symptom of meningitis and is more commonly associated with other conditions. While severe headache (Choice B) can be a symptom of meningitis, it is not as specific as a stiff neck. Coughing up blood (Choice D) is not a typical sign of meningitis and may indicate other respiratory or cardiovascular issues.

5. The client with chronic renal failure is being taught about fluid restrictions by the nurse. Which statement by the client indicates a need for further teaching?

• A. I can drink as much water as I want, as long as I limit my salt intake.
• B. I should limit my fluid intake to prevent fluid overload.
• C. I can skip dialysis sessions if I feel tired.
• D. I can eat whatever I want, as long as I take my medications.

Correct answer: C

Rationale: Choice C is the correct answer because clients with chronic renal failure should not skip dialysis sessions. Skipping dialysis can lead to serious complications and worsen the client's condition. It is crucial for clients to understand the importance of adhering to their dialysis schedule for optimal management of chronic renal failure. Choices A, B, and D are incorrect because they demonstrate understanding of fluid restrictions, the need to limit fluid intake to prevent overload, and the importance of medication compliance, respectively. These statements show appropriate knowledge and do not indicate a need for further teaching.

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