Nursing Elites

1. A client in the third trimester of pregnancy reports that she feels some 'lumpy places' in her breasts and that her nipples sometimes leak a yellowish fluid. She has an appointment with her healthcare provider in two weeks. What action should the nurse take?

• A. Instruct the client to immediately see her provider for an evaluation
• B. Assess the fluid for signs of infection
• C. Explain that this normal secretion can be assessed at the next visit
• D. Recommend breast ultrasound to rule out abnormalities

Correct answer: C

Rationale: The yellowish fluid is likely colostrum, a normal finding in late pregnancy as the breasts prepare for lactation. It is common for women in the third trimester to experience 'lumpy places' in the breasts due to increased milk duct development. In this situation, the nurse should educate the client that these findings are normal physiological changes associated with pregnancy. Since the client has an upcoming appointment with her healthcare provider in two weeks, it is appropriate to reassure her that this can be further assessed during that visit. Instructing the client to immediately see her provider (Choice A) is unnecessary as this is a common finding in late pregnancy. Assessing the fluid for signs of infection (Choice B) is not warranted as colostrum leakage is a normal occurrence. Recommending a breast ultrasound (Choice D) is premature without further assessment by the healthcare provider.

2. A client with a history of alcohol abuse presents with confusion and unsteady gait. The nurse suspects Wernicke's encephalopathy. Which treatment should the nurse anticipate?

• A. Thiamine supplementation
• B. Folic acid replacement
• C. Intravenous glucose
• D. Magnesium sulfate administration

Correct answer: A

Rationale: Wernicke's encephalopathy is a neurological condition commonly caused by a deficiency in thiamine, often seen in clients with chronic alcohol abuse. Thiamine supplementation is the primary treatment to prevent further neurological damage. Folic acid replacement (choice B) is not the correct treatment for Wernicke's encephalopathy. Intravenous glucose (choice C) may be necessary in some cases of Wernicke's encephalopathy, but thiamine supplementation takes precedence. Magnesium sulfate administration (choice D) is not indicated as the primary treatment for Wernicke's encephalopathy.

3. The psychiatric nurse is caring for clients in an adolescent unit. Which client requires the nurse's immediate attention?

• A. A 17-year-old client with schizophrenia who is pacing the hallways
• B. An 18-year-old client with antisocial behavior who is being yelled at by other clients
• C. A 16-year-old client with depression who refuses to eat meals
• D. A 15-year-old client with anxiety who is quietly reading in a corner

Correct answer: B

Rationale: The client with antisocial behavior being yelled at by peers may escalate the situation, potentially leading to violence or self-harm. Addressing the situation quickly helps prevent harm and de-escalates the conflict. Choices A, C, and D do not present immediate risks that require urgent intervention compared to the potential danger of a conflict escalating to violence with the client exhibiting antisocial behavior.

4. The nurse is preparing a female client for discharge after being treated for a urinary tract infection (UTI). Which statement by the client indicates a need for further teaching?

• A. I will use douches regularly to prevent future infections.
• B. I should drink at least 8 glasses of water a day.
• C. I should avoid tight-fitting clothing.
• D. I will wipe from front to back after using the toilet.

Correct answer: A

Rationale: The correct answer is A. Using douches is not recommended as it can disrupt the natural flora and increase the risk of infections. Choices B, C, and D are all correct statements that can help prevent UTIs. Drinking an adequate amount of water helps flush out bacteria, avoiding tight-fitting clothing promotes ventilation and reduces moisture, and wiping from front to back prevents the spread of bacteria from the anal region to the urethra.

5. A client with pancreatitis reports severe pain after eating fatty foods. What intervention should the nurse implement?

• A. Encourage the client to eat small, low-fat meals.
• B. Administer antispasmodic medication as prescribed.
• C. Instruct the client to avoid eating until the pain subsides.
• D. Increase the client’s intake of high-protein foods.

Correct answer: B

Rationale: In pancreatitis, pain after consuming fatty foods is common due to increased pancreatic stimulation. Administering antispasmodics is the appropriate intervention as it can help reduce the pain by decreasing pancreatic enzyme secretion. Encouraging the client to eat small, low-fat meals (Choice A) is beneficial in managing pancreatitis symptoms but does not directly address the acute pain. Instructing the client to avoid eating until the pain subsides (Choice C) may lead to nutritional deficiencies and is not the best approach. Increasing high-protein foods intake (Choice D) is not recommended as it can put additional strain on the pancreas.

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