Nursing Elites

1. A client presents to the clinic with concerns about her left breast. Which assessment finding is most important for the nurse to report?

• A. Multiple firm, round, freely movable masses.
• B. A slight asymmetry of the breasts.
• C. A fixed nodular mass with dimpling of the skin.
• D. Bloody discharge from the nipple.

Correct answer: C

Rationale: The correct answer is C. A fixed nodular mass with dimpling of the skin is concerning for malignancy, such as breast cancer, and should be reported immediately for further evaluation. This finding is more suspicious compared to multiple firm, round, freely movable masses (choice A), which could be benign breast lumps. A slight asymmetry of the breasts (choice B) is a common finding and not as alarming as a fixed nodular mass with dimpling of the skin. Bloody discharge from the nipple (choice D) can be suggestive of other conditions like intraductal papilloma but is not as urgent as the finding described in choice C.

2. The nurse is caring for a client receiving a blood transfusion who develops urticaria half an hour after the transfusion has begun. What is the first action the nurse should take?

• A. Stop the infusion
• B. Slow the rate of infusion
• C. Take vital signs and observe for further deterioration
• D. Administer Benadryl and continue the infusion

Correct answer: A

Rationale: The correct action for the nurse to take when a client develops urticaria during a blood transfusion is to immediately stop the infusion. Urticaria is a sign of a transfusion reaction, and stopping the infusion is crucial to prevent the reaction from worsening. Slowing the rate of infusion (Choice B) is not appropriate in this situation as the reaction has already started. While taking vital signs and observing for further deterioration (Choice C) is important, the priority is to stop the transfusion. Administering Benadryl and continuing the infusion (Choice D) is not recommended until the client's condition has stabilized and healthcare provider orders have been obtained.

3. When assessing constipation in elders, what action should be the nurse's priority?

• A. Obtain a complete blood count
• B. Obtain a health and dietary history
• C. Refer to a provider for a physical examination
• D. Measure height and weight

Correct answer: B

Rationale: Obtaining a detailed health and dietary history is crucial when assessing constipation in elders. This helps the nurse identify potential causes such as inadequate fluid intake, low fiber diet, lack of physical activity, or medications that could be contributing to constipation. A complete blood count (Choice A) is not the priority in the initial assessment of constipation. Referring to a provider for a physical examination (Choice C) would be done after gathering more information from the health history. Measuring height and weight (Choice D) is not directly relevant to assessing constipation and identifying its causes.

4. The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the UAP?

• A. Report any client complaint of pain or discomfort
• B. Weigh the client and report any weight gain
• C. Note and report the client's food and liquid intake during meals and snacks
• D. All of the above

Correct answer: D

Rationale: The UAP can be tasked with reporting complaints, monitoring weight gain, and tracking food and fluid intake, all of which are important in managing a client with Cushing's syndrome. These tasks fall within the UAP's scope of practice. Reporting client complaints helps in early identification of complications, monitoring weight is crucial due to fluid retention in Cushing's syndrome, and tracking food and fluid intake assists in dietary management. Choices A, B, and C are all necessary components of care for a client with Cushing's syndrome, making option D the correct answer.

5. The nurse is caring for a client who requires a mechanical ventilator for breathing. The high-pressure alarm goes off on the ventilator. What is the first action the nurse should perform?

• A. Disconnect the client from the ventilator and use a manual resuscitation bag
• B. Perform a quick assessment of the client's condition
• C. Call the respiratory therapist for help
• D. Press the alarm reset button on the ventilator

Correct answer: B

Rationale: The correct answer is to perform a quick assessment of the client's condition when the high-pressure alarm goes off on the ventilator. This assessment is crucial to determine the cause of the alarm and the client's current status. Option A is incorrect because disconnecting the client from the ventilator without assessing the situation can be harmful. Option C is incorrect as the nurse should first assess the client before seeking additional help. Option D is incorrect because resetting the alarm without understanding the underlying issue may lead to potential risks to the client.

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