Nursing Elites

1. A client is admitted with a diagnosis of pneumonia and is receiving IV antibiotics. Which assessment finding indicates that the treatment is effective?

• A. Client reports less chest pain.
• B. Client's white blood cell count is decreasing.
• C. Client has a decreased respiratory rate.
• D. Client has clear breath sounds.

Correct answer: D

Rationale: The correct answer is D. Clear breath sounds indicate that the pneumonia is resolving and the treatment is effective. Breath sounds are often muffled or crackling in pneumonia due to the presence of fluid or inflammation in the lungs. Clear breath sounds suggest that the air is moving freely through the lungs, indicating improvement. Choices A, B, and C are less specific indicators of pneumonia resolution. While less chest pain and a decreasing white blood cell count can be positive signs, they are not as direct in indicating the effectiveness of pneumonia treatment as the presence of clear breath sounds. A decreased respiratory rate could be seen in various conditions and may not solely indicate the resolution of pneumonia.

2. A nurse is teaching a client with type 2 diabetes about the importance of foot care. Which statement by the client indicates a need for further teaching?

• A. I should check my feet every day for cuts or blisters.
• B. I need to moisturize my feet daily, especially between my toes.
• C. I should wear comfortable shoes that fit well.
• D. I should avoid walking barefoot, even indoors.

Correct answer: B

Rationale: The correct answer is B. Moisturizing between the toes can create a moist environment that fosters fungal infections. Checking the feet daily for cuts or blisters (choice A) is correct in diabetes management to prevent complications. Wearing comfortable shoes that fit well (choice C) and avoiding walking barefoot (choice D) are also essential in preventing foot ulcers and injuries in diabetic patients.

3. An adult male with schizophrenia who has been noncompliant in taking oral antipsychotic medications refuses a prescribed IM medication. What action should the nurse take?

• A. Notify the healthcare provider of the client's refusal
• B. Attempt to convince the client to take the medication
• C. Administer the medication without the client's consent
• D. Document the refusal and take no further action

Correct answer: A

Rationale: The correct action is to notify the healthcare provider of the client's refusal. It is important for the healthcare provider to be informed so that they can decide on the next steps in the client's treatment, which may involve exploring alternative options or strategies. Attempting to convince the client to take the medication may not be effective, especially if the client is refusing. Administering the medication without the client's consent would violate the client's autonomy and rights. Simply documenting the refusal without further action may not address the client's treatment needs.

4. A 7-year-old boy is brought to the clinic because of facial edema. He reports that he has been voiding small amounts of dark, cloudy, tea-colored urine. The parents state that their son had a sore throat 2 weeks earlier, but it has resolved. After assessing the child's vital signs and weight, what intervention should the nurse implement next?

• A. Perform an otoscopic examination
• B. Measure the child's abdominal girth
• C. Collect a urine specimen for routine urinalysis
• D. Obtain a blood specimen for serum electrolytes

Correct answer: C

Rationale: Collecting a urine specimen for routine urinalysis is the next appropriate intervention. The symptoms described, including facial edema and tea-colored urine, are indicative of glomerulonephritis, a condition affecting the kidneys. A urine specimen can help assess renal function and the presence of blood and protein in the urine, which are common in glomerulonephritis. Performing an otoscopic examination (Choice A) is not relevant to the presenting symptoms. Measuring the child's abdominal girth (Choice B) is not necessary at this point as it does not directly address the urinary symptoms. Obtaining a blood specimen for serum electrolytes (Choice D) may provide information about electrolyte imbalances but is not the most appropriate initial step in this case.

5. The nurse is preparing to administer an enema to a client with severe constipation. Which position is most appropriate for the client?

• A. Supine with the head elevated 30 degrees
• B. Left lateral with the right leg flexed
• C. Sims’ position with the right leg flexed
• D. Prone position with the head turned to the side

Correct answer: C

Rationale: Sims’ position with the right leg flexed is the most appropriate position for administering an enema to a client with severe constipation. This position helps in promoting the flow of the enema solution into the rectum and facilitates the evacuation of stool. Supine position with the head elevated 30 degrees (Choice A) is not ideal for administering an enema as it does not facilitate the flow of the solution. Left lateral position with the right leg flexed (Choice B) is not the best choice for administering an enema. Prone position with the head turned to the side (Choice D) is also not suitable for administering an enema as it does not assist in the proper administration and retention of the solution.

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