Nursing Elites

1. The nurse observes bilateral bruises on the arms of an elderly client in a long-term care facility. Which of the following questions should the nurse ask this client?

• A. "How did you get those bruises?"?
• B. "Did someone grab you by your arms?"?
• C. "Do you fall often?"?
• D. "What did you bump against?"?

Correct answer: B

Rationale: The correct answer is asking, "Did someone grab you by your arms?"? This question is direct and addresses the possibility of abuse, which is crucial when dealing with suspected abuse cases. It is important to ask direct questions in a sensitive and non-accusatory manner to gather information. Choice A is too general and may not prompt a disclosure of abuse. Choice C assumes falling as the cause without addressing abuse directly. Choice D is vague and does not specifically inquire about potential abuse, making it less effective in identifying abuse cases compared to the correct choice.

2. Which of the following solutions is routinely used to flush an IV device before and after the administration of blood to a client?

• A. 0.9% sodium chloride
• B. 5% dextrose in water solution
• C. Sterile water
• D. Heparin sodium

Correct answer: A

Rationale: The correct answer is 0.9% sodium chloride. Normal saline is 0.9% sodium chloride, which has the same osmolarity as blood and does not cause cell lysis. Choices 2 and 3, 5% dextrose in water solution and sterile water, are hypotonic solutions that can lead to cell lysis. Choice 4, Heparin sodium, is an anticoagulant and is not routinely used to flush an IV device before and after the administration of blood.

3. The client is being assessed for possible pernicious anemia. Which finding would support this diagnosis?

• A. A weight loss of 10 pounds in 2 weeks
• B. Complaints of numbness and tingling in the extremities
• C. A red, beefy tongue
• D. A hemoglobin level of 12.0 g/dL

Correct answer: C

Rationale: The correct answer is a red, beefy tongue, which is characteristic of pernicious anemia due to the atrophy of the papillae on the tongue. This finding is known as glossitis. A red, beefy tongue is a classic sign of pernicious anemia. Choice A, weight loss of 10 pounds in 2 weeks, is non-specific and not a typical finding in pernicious anemia. Choice B, complaints of numbness and tingling in the extremities, are more indicative of peripheral neuropathy, a common symptom of vitamin B12 deficiency, which can be seen in pernicious anemia. Choice D, a hemoglobin level of 12.0 g/dL, falls within the normal range and does not specifically point towards pernicious anemia, which is characterized by low hemoglobin levels due to impaired absorption of vitamin B12.

4. The nurse is participating in discharge teaching for the postpartal client. The nurse is aware that an effective means of managing discomfort associated with an episiotomy after discharge is:

• A. Promethazine
• B. Aspirin
• C. Sitz baths
• D. Ice packs

Correct answer: C

Rationale: A sitz bath is an effective method for managing discomfort associated with an episiotomy after discharge. It helps reduce swelling and promotes healing in the perineal area. Ice packs (option D) are typically used immediately after delivery to provide pain relief. Promethazine (option A) and aspirin (option B) are not indicated for managing discomfort associated with an episiotomy. Promethazine is an antihistamine, and aspirin is a nonsteroidal anti-inflammatory drug, both of which are not commonly used for this purpose.

5. Which of the following roommates would be best for the client newly admitted with gastric resection?

• A. A client with Crohn's disease
• B. A client with pneumonia
• C. A client with gastritis
• D. A client with phlebitis

Correct answer: D

Rationale: The most suitable roommate for the client newly admitted with gastric resection is the client with phlebitis. Phlebitis is an inflammation of the blood vessel and is not infectious, making it a safer option for the surgical client. Crohn's disease clients (choice A) have frequent stools that might spread infections to the surgical client, posing a risk. A client with pneumonia (choice B) is coughing, which can disturb the gastric client's recovery. Additionally, a client with gastritis (choice C) who is vomiting and experiencing diarrhea would also not be an ideal roommate for a client recovering from gastric resection.

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