Nursing Elites

1. A client taking clopidogrel reports the onset of diarrhea. Which nursing action should the nurse implement first?

• A. Observe the appearance of the stool
• B. Assess the client’s skin turgor
• C. Review the client’s laboratory values
• D. Auscultate the client’s bowel sounds

Correct answer: A

Rationale: Observing the stool’s appearance should be implemented first as it helps determine the nature and possible severity of the diarrhea, which is essential in managing the side effect. Assessing skin turgor (Choice B) is not the priority in this situation. Reviewing laboratory values (Choice C) can provide additional information but is not the initial step. Auscultating bowel sounds (Choice D) is not the priority when the client is experiencing diarrhea.

2. A 10-month-old girl is admitted with a diagnosis of possible cystic fibrosis. What question should the nurse ask the parent to assist in the diagnosis of cystic fibrosis (CF)?

• A. When you kiss her, does she taste salty?
• B. Do you notice if her urine has a musty odor?
• C. Has she been drinking cow's milk in her daily diet?
• D. How often does she have a normal bowel movement?

Correct answer: A

Rationale: The correct answer is A. Salty skin is a common sign of cystic fibrosis due to high levels of sodium in sweat. Asking about the taste of the child's skin provides valuable information related to the diagnosis of CF. Choices B, C, and D are not helpful in diagnosing cystic fibrosis. A musty odor in urine is not a typical symptom of CF. Drinking cow's milk or bowel movement frequency are not specific to CF diagnosis.

3. When the client asks the nurse if they have ever been with someone when they died, what is the nurse’s best response?

• A. “Yes, I have. Do you have some questions about dying?”
• B. “Several times. Now, let’s get your dressing changed.”
• C. “A few times. It was peaceful and there was no pain.”
• D. “Yes, but you’re doing great. Are you concerned about dying?”

Correct answer: A

Rationale: Choice A is the best response as it acknowledges the client's question and opens the door for further discussion about dying if the client wishes to. It shows empathy and encourages the client to express any concerns they may have. Choices B and C do not directly address the client's question or offer an opportunity for him to explore his concerns. Choice D acknowledges the experience but fails to address the client's question directly and does not encourage further discussion.

4. What is the best response when a two-year-old boy begins to cry when his mother starts to leave?

• A. Say, 'Let's wave bye-bye to Mommy.'
• B. Say, 'Let me read this book to you.'
• C. Say, 'Two-year-olds usually stop crying the minute the parent leaves.'
• D. Say, 'Now, now, be a big boy, Mommy will be back soon.'

Correct answer: B

Rationale: The best response in this situation is to offer a distraction to the child. Reading a book can help soothe the child during separation from the parent by redirecting their attention. Choice A might not be as effective as providing a distraction like reading a book. Choice C dismisses the child's feelings and generalizes behavior, which is not helpful. Choice D diminishes the child's emotions and does not provide a constructive way to help the child cope with the separation anxiety.

5. In what order should the unit manager implement interventions to address the UAP’s behavior after they leave the unit without notifying the staff?

• A. Note date and time of the behavior.
• B. Discuss the issue privately with the UAP.
• C. Plan for scheduled break times.
• D. Evaluate the UAP for signs of improvement.

Correct answer: A

Rationale: The correct order for the unit manager to implement interventions to address the UAP's behavior is to first note the date and time of the behavior. Proper documentation is crucial as it provides a factual record of the incident. This documentation can be used to address the behavior effectively and to track any patterns or improvements in the future. Discussing the issue with the UAP privately (choice B) should come after documenting the behavior. Planning for scheduled break times (choice C) is unrelated to the situation described and does not address the UAP's behavior of leaving without notifying the staff. Evaluating the UAP for signs of improvement (choice D) can only be done effectively after the behavior has been addressed and interventions have been implemented.

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