Nursing Elites

1. A nurse in a provider’s office is caring for a client who states, “I always have trouble sleeping.” Which of the following actions should the nurse take first?

• A. Teach the client stress reduction techniques
• B. Recommend that the client avoid caffeine intake in the evening
• C. Identify the client’s typical bedtime routine
• D. Encourage the client to exercise regularly during daytime hours

Correct answer: C

Rationale: The correct action for the nurse to take first is to identify the client’s typical bedtime routine. Understanding the client’s sleep habits, environment, and bedtime rituals can provide valuable insight into potential factors contributing to their sleep troubles. Teaching stress reduction techniques (choice A) may be beneficial but should come after understanding the client's routine. Recommending avoiding caffeine intake in the evening (choice B) and encouraging regular daytime exercise (choice D) are important interventions, but identifying the bedtime routine takes precedence as it directly addresses the client's immediate concern.

2. A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2 degrees C (102 degrees F), heart rate of 105/min, a soft tender abdomen, and census overdue by 2 days. Which of the following findings should be the nurse's priority?

• A. Temperature
• B. Heart rate
• C. Abdominal tenderness
• D. Census overdue

Correct answer: A

Rationale: The correct answer is A: Temperature. A high fever is a significant indicator of infection or other serious conditions, making it the priority finding. Elevated temperature indicates an immediate concern for infection, which can quickly escalate and lead to severe complications if not addressed promptly. While heart rate, abdominal tenderness, and census overdue are important aspects to consider in the client's care, addressing the fever takes precedence due to its potential severity and implications for the client's health.

3. A nurse in a provider's office is preparing to assess a young adult client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect?

• A. Concave thoracic spine posteriorly
• B. Exaggerated lumbar curvature
• C. Concave lumbar spine posteriorly
• D. Exaggerated thoracic curvature

Correct answer: B

Rationale: When assessing a young adult's musculoskeletal system, the nurse should expect an exaggerated lumbar curvature (lordosis). This is a normal finding in young adults due to the natural curvature of the spine. Concave thoracic spine posteriorly (choice A) and concave lumbar spine posteriorly (choice C) are not typical findings as the spine should have normal curvatures. Exaggerated thoracic curvature (choice D) is also not a typical finding in young adults.

4. When moving a patient up in bed using a drawsheet with the help of another nurse, in which order will the nurses perform the steps, starting with the first one?

• A. Grasp the drawsheet firmly near the patient.
• B. Move the patient and drawsheet to the desired position.
• C. Position one nurse at each side of the bed.
• D. Place the drawsheet under the patient from shoulder to thigh.

Correct answer: C

Rationale: When moving a patient up in bed with a drawsheet and the assistance of another nurse, it is important to have one nurse positioned at each side of the bed initially. This allows for proper coordination and support during the patient movement. Placing the drawsheet under the patient from shoulder to thigh, grasping the drawsheet firmly near the patient, and moving the patient and drawsheet to the desired position follow after the nurses are positioned on each side of the bed. The correct sequence ensures a safe and coordinated approach to repositioning the patient in bed.

5. A nurse in an outpatient clinic is caring for a client who has a new prescription for an antihypertensive medication. Which of the following instructions should the nurse give the client?

• A. “Get up and change positions slowly.”
• B. “Avoid eating aged cheese and smoked meat.”
• C. “Report any unusual bruising or bleeding to the doctor immediately.”
• D. “Eat the same amount of foods that contain vitamin K every day.”

Correct answer: A

Rationale: The correct instruction for the nurse to give the client who is starting on antihypertensive medication is to 'Get up and change positions slowly.' Antihypertensive medications can cause orthostatic hypotension, a drop in blood pressure when changing positions, so changing positions slowly helps prevent this adverse effect. Choice B about avoiding aged cheese and smoked meat is more relevant for clients taking monoamine oxidase inhibitors (MAOIs) due to potential interactions. Choice C regarding reporting unusual bruising or bleeding is more applicable for clients on anticoagulants. Choice D about consuming consistent amounts of vitamin K-containing foods daily is important for clients taking warfarin, not antihypertensive medications.

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