Nursing Elites

1. In the Emergency Department, a female client discloses that she was raped last night. Which question is most important for the nurse to ask?

• A. Does she know the person who raped her?
• B. Has she taken a bath since the rape occurred?
• C. Is the place where she lives a safe place?
• D. Did she report the rape to the police department?

Correct answer: A

Rationale: The most important question for the nurse to ask in this situation is whether the client knows the person who raped her. This question is crucial for assessing additional safety concerns, providing appropriate support, and determining the need for forensic evidence collection. Choices B, C, and D are not as critical in the immediate assessment and response to a rape victim. Asking about bathing, the safety of her home, or reporting to the police may be important but are secondary to identifying the perpetrator for safety and legal reasons.

2. An IV antibiotic is prescribed for a client with a postoperative infection. The medication is to be administered in 4 divided doses. What schedule is best for administering this prescription?

• A. 1000, 1600, 2200, 0400
• B. Give in equally divided doses during waking hours
• C. Administer with meals and a bedtime snack
• D. 0800, 1200, 1600, 2000

Correct answer: D

Rationale: The best schedule for administering the IV antibiotic in 4 divided doses is 0800, 1200, 1600, and 2000. This timing allows for equal spacing between doses, ensuring consistent therapeutic levels of the medication in the client's system. Choice A provides doses too close together, increasing the risk of medication errors and potential toxicity. Choice B's suggestion of giving doses during waking hours is vague and lacks specific timing, which may result in irregular dosing intervals. Choice C, administering with meals and a bedtime snack, is unrelated to the timing of the antibiotic doses and does not optimize the drug's effectiveness.

3. The nurse is caring for a group of clients on a surgical unit. Which client should the nurse assess first?

• A. A client who is two days post knee surgery and describes pain at a “4” on a 1 to 10 scale
• B. A client who is one day post bowel resection with no bowel sounds
• C. A client who is 8 hours post appendectomy with urinary output of 480 ml
• D. A client who was admitted with severe abdominal pain and suddenly has no pain

Correct answer: D

Rationale: The correct answer is D. A sudden absence of pain in a client with severe abdominal pain may indicate a serious condition such as internal bleeding. This sudden change in pain status requires immediate assessment to rule out any life-threatening complications. Choices A, B, and C do not indicate an acute change in the client's condition that would necessitate immediate attention compared to sudden pain relief in a client with severe abdominal pain.

4. When administering diazepam, a benzodiazepine, 10 mg IV push PRN for a client with alcohol withdrawal symptoms, which actions should the nurse implement? (Select all that apply)

• A. Protect the medication from light exposure
• B. Monitor for changes in level of consciousness
• C. Observe for onset of generalized bruising or bleeding
• D. Perform ongoing assessment of respiratory status

Correct answer: D

Rationale: When administering diazepam for a client with alcohol withdrawal symptoms, it is crucial to perform ongoing assessment of respiratory status. Diazepam can lead to respiratory depression, emphasizing the need for continuous monitoring to detect any signs of respiratory distress early. Protecting the medication from light exposure is a general guideline for some drugs but is not a specific concern for diazepam. Observing for bruising or bleeding is not directly associated with the administration of diazepam for alcohol withdrawal symptoms, making choices A and C incorrect.

5. Parents who have one male child with sickle cell anemia are concerned about having more children with the disease. What client teaching should the nurse provide?

• A. All future children will be carriers, but will not necessarily have the disease
• B. There is a chance that each future child will have the disease
• C. Only male children cannot inherit the sickle cell disease trait
• D. Only one out of four of their children will definitely manifest the disease

Correct answer: B

Rationale: The correct answer is B. Each child has a 25% chance of having sickle cell anemia if both parents are carriers of the trait. Choice A is incorrect because not all future children will be carriers; some may have the disease. Choice C is incorrect as both male and female children can inherit the sickle cell disease trait. Choice D is incorrect as the chance is not fixed at one out of four; each child has an independent 25% chance of having the disease.

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