Nursing Elites

1. 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.

2. A client is prescribed spironolactone. Which of the following dietary instructions should the nurse include?

• A. Increase potassium-rich foods
• B. Limit sodium intake
• C. Avoid potassium supplements
• D. Increase protein intake

Correct answer: C

Rationale: The correct answer is to advise the client to avoid potassium supplements. Spironolactone is a potassium-sparing diuretic, meaning it helps the body retain potassium. Adding potassium supplements on top of this medication can lead to hyperkalemia, an elevated level of potassium in the blood, which can be dangerous. Choices A, B, and D are incorrect because increasing potassium-rich foods, limiting sodium intake, and increasing protein intake are not specifically related to the dietary considerations when taking spironolactone.

3. A nurse in an acute care facility is caring for a client who is postop following abdominal surgery. Which of the following behaviors should the nurse identify as increasing the client's risk for constipation?

• A. Regular fluid intake
• B. Urge suppression
• C. Increased physical activity
• D. Adequate dietary fiber

Correct answer: B

Rationale: Urge suppression can lead to constipation by delaying bowel movements and causing fecal impaction, especially in postoperative patients. Regular fluid intake (choice A) is important to prevent constipation by maintaining hydration and aiding in bowel movements. Increased physical activity (choice C) helps stimulate bowel function and prevent constipation. Adequate dietary fiber (choice D) is essential for promoting healthy bowel movements and preventing constipation. However, urge suppression (choice B) is the behavior that directly contributes to constipation in this scenario.

4. A nurse in an outpatient facility is assessing a client who is prescribed furosemide 40 mg daily, but the client reports she has been taking extra doses to promote weight loss. Which of the following findings indicates she is dehydrated?

• A. Urine specific gravity of 1.020
• B. Urine specific gravity of 1.035
• C. Decreased skin turgor
• D. Decreased heart rate

Correct answer: B

Rationale: The correct answer is B. A urine specific gravity greater than 1.030 is indicative of dehydration as it reflects concentrated urine. Choice A is incorrect as a specific gravity of 1.020 is within the normal range. Choice C, decreased skin turgor, can be a sign of dehydration but is not as specific as urine specific gravity. Choice D, decreased heart rate, is not typically a direct indicator of dehydration.

5. A nurse is caring for a newborn with hyperbilirubinemia. Which of the following interventions should be taken during phototherapy?

• A. Maintain an eye mask over the newborn's eyes
• B. Feed the newborn every hour
• C. Monitor the newborn's temperature
• D. Administer vitamin K

Correct answer: A

Rationale: During phototherapy for a newborn with hyperbilirubinemia, it is crucial to maintain an eye mask over the newborn's eyes. The purpose of the eye mask is to protect the infant's eyes from potential damage caused by the intense light used in phototherapy. While feeding the newborn frequently and monitoring temperature are essential aspects of newborn care, they are not specific to phototherapy. Administering vitamin K is important for newborns to prevent bleeding disorders but is not directly related to phototherapy for hyperbilirubinemia.

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