Nursing Elites

1. A nurse enters a patient's room and finds the client pulseless. The living will requests no resuscitation be performed, but the provider has not written the prescription. What action should the nurse take?

• A. Notify the family.
• B. Begin CPR.
• C. Await further instructions from the provider.
• D. Document the event.

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to begin CPR. Even though the living will requests no resuscitation, without a written do-not-resuscitate (DNR) order from the provider, the nurse is ethically and legally bound to initiate CPR to provide life-saving measures until further confirmation is obtained. Notifying the family (Choice A) may cause a delay in providing immediate care. Waiting for further instructions (Choice C) can be time-consuming and compromise patient outcomes. Documenting the event (Choice D) is important but should follow after initiating CPR to ensure patient safety and adherence to protocols.

2. A nurse in an urgent-care clinic is collecting admission history from a client who is 16 weeks gestation and has bacterial vaginosis. The nurse should recognize that which of the following clinical findings are associated with this infection?

• A. Frequency and dysuria
• B. Profuse milky white discharge
• C. Hematuria
• D. Low-grade fever

Correct answer: B

Rationale: Bacterial vaginosis often presents with a profuse, milky white discharge and a characteristic fishy odor, without significant inflammation, hematuria, or fever. Choice A, frequency, and dysuria are more indicative of a urinary tract infection. Choice C, hematuria, is associated with conditions like urinary tract infections or kidney problems. Choice D, low-grade fever, is not a typical symptom of bacterial vaginosis.

3. A nurse has been caring for a female client who has bruises on her arms that she explains are a result of physical abuse by her husband. The client states, “I don’t know how much longer I can take this, but I’m afraid he’ll really hurt me if I leave.” Which of the following is an appropriate nursing intervention?

• A. Offer to speak to the client’s husband regarding his abusive behavior
• B. Help the client to recognize signs of escalation in abusive behavior
• C. Assist the client in identifying personal behaviors that trigger abuse
• D. Assist the client in reporting the abusive behavior to authorities

Correct answer: D

Rationale: Assisting the client in reporting the abuse is a critical step in ensuring her safety and initiating legal action to protect her from further harm. Option A is inappropriate as it may escalate the situation and put the client at further risk. Option B focuses on the client recognizing signs of abuse, which is not as urgent as reporting it to authorities. Option C places the responsibility on the client for triggering the abuse, which is victim-blaming and not helpful in this context.

4. A nurse is preparing to teach a client with chronic renal failure. Which dietary instruction is most appropriate?

• A. Increase calcium intake
• B. Increase potassium intake
• C. Increase protein intake
• D. Restrict protein intake

Correct answer: D

Rationale: The correct answer is to restrict protein intake for a client with chronic renal failure. In renal failure, the kidneys are unable to effectively filter waste products. Excessive protein intake can lead to the accumulation of waste products, increasing the workload on the kidneys. Therefore, restricting protein intake is essential to prevent further kidney damage. Choices A, B, and C are incorrect. Increasing calcium intake is not specifically indicated for chronic renal failure. Increasing potassium intake can be dangerous in renal failure as impaired kidneys may not be able to excrete excess potassium. Increasing protein intake is contraindicated in chronic renal failure as it can worsen kidney function and increase the accumulation of waste products.

5. A client with Ménière’s disease is experiencing episodes of vertigo. Which of the following interventions should the nurse include in the plan?

• A. Encourage bed rest
• B. Restrict fluid intake to the morning hours
• C. Administer aspirin
• D. Provide a low sodium diet

Correct answer: D

Rationale: The correct intervention for a client with Ménière’s disease experiencing vertigo is to provide a low sodium diet. Limiting sodium helps to reduce fluid retention, which in turn decreases the manifestations of Ménière’s disease. Encouraging bed rest (Choice A) may be necessary during acute episodes but is not a long-term solution. Restricting fluid intake (Choice B) to the morning hours does not specifically address the underlying issue of fluid retention associated with Ménière’s disease. Administering aspirin (Choice C) is not recommended for Ménière’s disease as it can worsen symptoms.

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