Nursing Elites

1. A client is scheduled to have a blood test for cholesterol and triglycerides the next day. The nurse would tell the client

• A. ''Be sure to eat a fat-free diet until the test.''
• B. ''Do not eat or drink anything but water for 12 hours before the blood test.''
• C. ''Have the blood drawn within 2 hours of eating breakfast.''
• D. ''Stay at the laboratory so 2 blood samples can be drawn an hour apart.''

Correct answer: B

Rationale: Fasting for at least 12 hours is necessary before a cholesterol and triglyceride test to ensure accurate results by avoiding fluctuations that can occur after eating. Choice A is incorrect because a fat-free diet is not required; fasting is. Choice C is incorrect as it suggests having the test right after eating, which can affect the results. Choice D is incorrect as there is no need to stay at the laboratory for 2 blood samples unless specifically instructed by a healthcare provider.

2. A client asks the nurse about including her 2 and 12-year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse?

• A. Focus on your sons' needs during the first days at home.
• B. Tell each child what he can do to help with the baby.
• C. Suggest that your husband spend more time with the boys.
• D. Ask the children what they would like to do for the newborn.

Correct answer: A

Rationale: The correct answer is A. Focusing on the older children's needs during the initial days at home is crucial as it helps them feel secure and valued during the transition. This approach allows the children to adjust to the new family dynamics and feel included in the care of their newborn sister. Choice B is incorrect as it focuses on tasks rather than addressing the children's emotional needs. Choice C is not the initial step and does not involve directly addressing the children's needs. Choice D puts the decision-making burden on the children rather than providing guidance and support.

3. When providing nursing care to a client receiving oxygen therapy via a nasal cannula, which of the following interventions would be appropriate?

• A. Ensure that adequate mist is supplied
• B. Inspect the nares and ears for skin breakdown
• C. Lubricate the tips of the cannula before insertion
• D. Maintain sterile technique when handling the cannula

Correct answer: B

Rationale: The correct answer is to inspect the nares and ears for skin breakdown. This is important because the nasal cannula can cause skin breakdown due to prolonged use and friction. Ensuring that the skin is intact helps prevent complications. Choice A is incorrect as oxygen therapy via a nasal cannula does not involve mist. Choice C is incorrect as lubricating the tips of the cannula is not a standard practice and may lead to complications. Choice D is incorrect because while cleanliness is important, maintaining sterile technique is not necessary for handling a nasal cannula in this context.

4. A client with a history of alcoholism is admitted to the hospital for detoxification. The nurse knows that the client's risk for withdrawal symptoms is greatest within:

• A. 2-4 hours
• B. 4-6 hours
• C. 6-12 hours
• D. 12-24 hours

Correct answer: D

Rationale: The correct answer is D: 12-24 hours. Withdrawal symptoms typically begin within 12-24 hours after the last drink. This period is when the client is at the highest risk for experiencing withdrawal symptoms. Choices A, B, and C are incorrect because they do not align with the typical timeline for alcohol withdrawal symptoms to manifest. Symptoms usually peak within the first 24 to 48 hours after the last drink, making the 12-24 hour window critical for monitoring and managing any potential withdrawal complications.

5. A female client diagnosed with genital herpes simplex virus 2 (HSV 2) complains of dysuria, dyspareunia, leukorrhea, and lesions on the labia and perianal skin. A primary nursing action with the focus of comfort should be to

• A. Suggest 3 to 4 warm sitz baths per day
• B. Cleanse the genitalia twice a day with soap and water
• C. Spray warm water over genitalia after urination
• D. Apply heat or cold to lesions as desired

Correct answer: A

Rationale: The correct answer is to suggest 3 to 4 warm sitz baths per day. Warm sitz baths can soothe the irritated genital area, reduce pain, and promote healing of the lesions associated with genital herpes. Cleansing the genitalia with soap and water or spraying warm water over the genitalia after urination may further irritate the lesions. Applying heat or cold to lesions as desired may not provide the same level of comfort and healing as warm sitz baths.

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