Nursing Elites

1. A newly graduated female staff nurse requests reassignment to another client because a male client is asking her for a date and making suggestive comments. Which response is best for the nurse manager to provide?

• A. I have to call the supervisor to get someone else to transfer to this unit to care for him.
• B. I know you are a good nurse and can handle this client in a professional manner.
• C. I'll talk to the client about his behavior and insist that he stop it immediately.
• D. I'll change your assignment, but let's talk about how a nurse should respond to this kind of client.

Correct answer: D

Rationale: The best response for the nurse manager to provide in this situation is option D, which involves changing the assignment to address the nurse's immediate concern. It also offers an opportunity to have a conversation with the nurse about how to professionally handle such situations in the future. Option A is not the best response as it does not address the underlying issue and simply shifts the problem to another staff member. Option B, while supportive, does not actively address the client's inappropriate behavior. Option C is not ideal as the nurse manager should handle discussions about inappropriate behavior with clients themselves rather than delegating it to the staff nurse.

2. A client with a history of hypertension is prescribed a beta-blocker. Which client statement indicates that further teaching is needed?

• A. ‘I will take my medication in the morning before breakfast.’
• B. ‘I should avoid eating foods high in potassium.’
• C. ‘I should change positions slowly to avoid dizziness.’
• D. ‘I should avoid abrupt discontinuation of the medication.’

Correct answer: B

Rationale: The correct answer is B: ‘I should avoid eating foods high in potassium.’ This statement indicates a misunderstanding as beta-blockers do not typically affect potassium levels. The other choices (A, C, and D) are all appropriate statements for a client prescribed a beta-blocker. Choice A shows understanding of the timing of medication administration, choice C addresses orthostatic hypotension concerns, and choice D highlights the importance of not abruptly stopping the medication to prevent adverse effects.

3. A female client reports that she drank a liter of a solution to cleanse her intestines but vomited immediately after. How many ml of fluid intake should the nurse document?

• A. 1000 ml
• B. 800 ml
• C. 760 ml
• D. 500 ml

Correct answer: C

Rationale: The correct answer is 760 ml. One liter equals 1000 ml. As the client vomited immediately after drinking, she would have expelled approximately 240 ml (1 cup). Subtracting this from the initial intake of 1000 ml gives us 760 ml as the remaining fluid intake that should be documented. Choices A, B, and D are incorrect because they do not reflect the correct calculation of subtracting the amount vomited from the initial intake.

4. The nurse is reinforcing home care instructions with a client who is being discharged following a transurethral resection of the prostate (TURP). Which intervention is most important for the nurse to include in the client's instructions?

• A. Avoid strenuous activity for 6 weeks.
• B. Report fresh blood in the urine.
• C. Take acetaminophen for fever of 101°F.
• D. Consume 6 to 8 glasses of water daily.

Correct answer: B

Rationale: Reporting fresh blood in the urine is crucial following a TURP procedure as it may indicate a complication such as bleeding or clot formation. This symptom requires immediate attention to prevent further complications. Choices A, C, and D are important aspects of post-TURP care, but identifying and reporting fresh blood in the urine take precedence due to its association with potential serious complications.

5. A client with rheumatoid arthritis is prescribed methotrexate. Which laboratory value should the nurse monitor closely?

• A. White blood cell count of 10,000/mm³
• B. Hemoglobin of 12 g/dL
• C. Liver function tests
• D. Platelet count of 150,000/mm³

Correct answer: C

Rationale: The correct answer is C: Liver function tests. Methotrexate can cause hepatotoxicity, making it essential to closely monitor liver function tests in clients receiving this medication. Monitoring white blood cell count, hemoglobin, or platelet count is not specifically required for methotrexate therapy and would not provide relevant information regarding potential adverse effects of the medication.

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