Nursing Elites

1. A nurse is assessing a client who is receiving chemotherapy and has stomatitis. Which of the following findings should the nurse expect?

• A. Dry, cracked lips
• B. Bleeding gums
• C. Foul-smelling breath
• D. Red, open sores in the mouth

Correct answer: D

Rationale: The correct answer is D: Red, open sores in the mouth. Stomatitis, a common side effect of chemotherapy, presents with red, open sores in the mouth, which can be painful and increase the risk of infection. Choices A, B, and C are incorrect because stomatitis typically does not manifest as dry, cracked lips, bleeding gums, or foul-smelling breath.

2. A nurse is assisting with mass casualty triage following an explosion at a local factory. Which of the following clients should the nurse identify as the priority?

• A. A client who has massive head trauma
• B. A client who has full-thickness burns to the face and trunk
• C. A client with indications of hypovolemic shock
• D. A client with an open fracture of the lower extremity

Correct answer: C

Rationale: In a mass casualty situation, the nurse should prioritize the client with indications of hypovolemic shock. Hypovolemic shock is an immediate life-threatening condition resulting from severe blood loss, which can lead to organ failure and death. Prompt identification and treatment of hypovolemic shock are crucial to prevent further deterioration. While clients with massive head trauma, full-thickness burns, and open fractures require urgent care, hypovolemic shock takes precedence due to its rapid progression to a critical state.

3. A nurse is caring for a client prescribed prednisone. Which of the following should the nurse monitor?

• A. Blood glucose levels
• B. Serum potassium levels
• C. Liver function tests
• D. Heart rate

Correct answer: A

Rationale: Corrected Rationale: Prednisone is known to cause hyperglycemia by increasing blood glucose levels. Monitoring blood glucose levels is crucial to detect and manage any potential hyperglycemic effects of prednisone. While prednisone can also affect serum potassium levels and liver function, the priority monitoring parameter in this case is blood glucose levels. Monitoring heart rate is not directly associated with prednisone administration, making it a less relevant parameter to monitor in this scenario.

4. A client is prescribed tramadol for pain management. Which of the following should the nurse educate the client about?

• A. It is a non-opioid analgesic
• B. It can cause sedation
• C. It has no risk for dependence
• D. It can be taken as needed

Correct answer: B

Rationale: The correct answer is B. Tramadol can cause sedation, so the nurse should educate the client about this potential side effect. Choice A is incorrect because tramadol is actually an opioid analgesic. Choice C is incorrect as tramadol does carry a risk for dependence, especially with prolonged use. Choice D is not entirely accurate as tramadol is usually prescribed on a scheduled basis rather than as needed.

5. A nurse is preparing to insert an indwelling urinary catheter into a female client. Which of the following actions should the nurse take?

• A. Inflate the balloon with 10 mL of sterile water prior to insertion
• B. Cleanse the client’s labia and meatus using a front-to-back motion
• C. Ask the client to bear down while inserting the catheter
• D. Inflate the catheter balloon after urine begins to flow

Correct answer: D

Rationale: The correct action for the nurse to take when inserting an indwelling urinary catheter into a female client is to inflate the catheter balloon after urine begins to flow. Inflating the balloon before urine starts flowing can lead to incorrect placement in the urethra, causing trauma. Cleansing the labia and meatus should be done before the insertion, but the crucial step of inflating the balloon should occur after the catheter is correctly placed. Asking the client to bear down is not necessary during catheter insertion.

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