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 with a fractured femur is in Buck's traction. The nurse should assess for which of the following complications?

• A. Foot drop
• B. Urinary retention
• C. Constipation
• D. Muscle spasms

Correct answer: A

Rationale: Corrected Rationale: Foot drop is a potential complication of prolonged immobility and improper positioning in traction. In Buck's traction, the lower extremity is suspended to immobilize and align the fractured femur. Prolonged suspension of the leg in traction can lead to nerve damage, specifically to the common peroneal nerve, resulting in foot drop. Urinary retention, constipation, and muscle spasms are not directly associated with Buck's traction and a fractured femur.

3. The nurse working in a community health clinic that serves recent Somali immigrants notes that most mothers refuse to give permission for routine immunizations of their preschoolers. Which individual is likely to have the most influence on these women's perceptions about their children's healthcare needs?

• A. husbands
• B. clinic healthcare providers
• C. older females
• D. tribal chief

Correct answer: D

Rationale: In many Somali communities, the tribal chief holds significant influence over health decisions. The tribal chief often plays a crucial role in shaping community beliefs and practices, including healthcare decisions. While husbands may have some influence, the tribal chief typically holds more authority in community matters. Clinic healthcare providers have a role in educating and advising, but the tribal chief's influence is often more profound in this cultural context. Older females may have some influence, especially in familial matters, but the tribal chief is usually the key decision-maker in community health issues.

4. What does the nurse perform to determine the family nursing problems/needs?

• A. goal setting
• B. family health care plan formulation
• C. assessment
• D. evaluation

Correct answer: C

Rationale: The correct answer is C: assessment. Assessment is the initial step in identifying family nursing problems/needs. During assessment, the nurse collects data to understand the family's health status, strengths, weaknesses, and potential areas for intervention. This process helps in developing an accurate picture of the family's situation. Choices A, B, and D are incorrect because goal setting, family health care plan formulation, and evaluation come after the assessment phase. Goal setting occurs once the issues are identified, the family health care plan is developed based on assessment findings, and evaluation is the final step to assess the effectiveness of the interventions implemented.

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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