Nursing Elites

1. A 20-year-old female client calls the nurse to report a lump she found in her breast. Which response is the best for the nurse to provide?

• A. Check it again in one month, and if it is still there schedule an appointment.
• B. Most lumps are benign, but it is always best to come in for an examination.
• C. Try not to worry too much about it, because usually, most lumps are benign.
• D. If you are in your menstrual period it is not a good time to check for lumps.

Correct answer: B

Rationale: The nurse advising the client to come in provides the best response because it addresses the client's anxiety most effectively and encourages prompt and immediate action for a potential problem.

2. Polyethylene glycol–electrolyte solution (GoLYTELY) is prescribed for a hospitalized client scheduled for a colonoscopy. The client begins to experience diarrhea after drinking the solution. Which action by the nurse is appropriate?

• A. Calling the physician
• B. Administering a cleansing enema
• C. Documenting the diarrhea in the medical record
• D. Giving intravenous replacement fluids in large amounts

Correct answer: C

Rationale: The correct action by the nurse in this situation is to document the diarrhea in the medical record. Polyethylene glycol–electrolyte solution (GoLYTELY) is a bowel evacuant used to cleanse the bowel before a colonoscopy. It is expected to cause mild diarrhea, which is a normal response to the medication. The diarrhea helps clear the bowel in preparation for the procedure. Calling the physician is not necessary unless there are complications. Administering a cleansing enema or giving intravenous replacement fluids in large amounts are not appropriate actions as they are not indicated for managing the expected diarrhea caused by GoLYTELY.

3. A female patient who is allergic to penicillin will begin taking an antibiotic to treat a lower respiratory tract infection. The patient tells the nurse that she almost always develops a vaginal yeast infection when she takes antibiotics and that she will take fluconazole (Diflucan) with the antibiotic being prescribed. Which macrolide should the nurse question for this patient?

• A. Azithromycin (Zithromax)
• B. Clarithromycin (Biaxin)
• C. Erythromycin (E-Mycin)
• D. Fidaxomicin (Dificid)

Correct answer: C

Rationale: The nurse should question the prescription of erythromycin for this patient. When erythromycin is given concurrently with fluconazole, erythromycin blood concentration and the risk of sudden cardiac death increase. Therefore, it is not recommended to use erythromycin in combination with fluconazole for this patient. Azithromycin, clarithromycin, and fidaxomicin are alternative macrolide antibiotics that can be considered for this patient without the same risk of interactions when used with fluconazole.

4. When preparing a client who has had a total laryngectomy for discharge, what instruction is most important for the nurse to include in the discharge teaching?

• A. Recommend that the client carry suction equipment at all times.
• B. Instruct the client to have writing materials with them at all times.
• C. Tell the client to carry a medic alert card stating that they are a total neck breather.
• D. Tell the client not to travel alone.

Correct answer: C

Rationale: The most crucial instruction for a client who has had a total laryngectomy is to carry a medic alert card stating that they are a total neck breather. This is important because if they experience a cardiac arrest, mouth-to-neck breathing may be required. Choice A about carrying suction equipment is not the most critical as the client may not always need it. Choice B is not as essential as having a medic alert card. Choice D is not directly related to the client's safety due to their laryngectomy.

5. In a client with heart failure presenting bilateral +4 edema of the right ankle extending up to midcalf while sitting with legs dependent, what is the priority goal?

• A. Decrease venous congestion.
• B. Maintain normal respirations.
• C. Maintain body temperature.
• D. Prevent injury to lower extremities.

Correct answer: A

Rationale: The priority goal in this scenario is to decrease venous congestion. By elevating the legs above the heart level, venous return is improved, reducing congestion in the lower extremities. This intervention helps decrease swelling and prevents complications such as impaired tissue perfusion. Maintaining normal respirations and body temperature are important aspects of care but are secondary to addressing the immediate issue of venous congestion. Preventing injury to lower extremities is also essential but takes precedence after managing the venous congestion to prevent further complications.

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