Nursing Elites

1. A nurse is caring for a young adult at a college health clinic. Which of the following actions should the nurse take first?

• A. Give the client information about immunization against meningitis.
• B. Tell the client to have a TB skin test every 2 years.
• C. Determine the client’s health risks.
• D. Teach the client about exercise recommendations.

Correct answer: C

Rationale: Assessing the client’s health risks is the priority as it provides essential information to guide subsequent care. By understanding the client’s health risks, the nurse can tailor health education and interventions, such as immunizations and lifestyle modifications, to address specific needs. Providing information about immunization against meningitis (Choice A) is important but should come after assessing health risks. Instructing the client to have a TB skin test every 2 years (Choice B) is relevant but not the initial step in care. Teaching about exercise recommendations (Choice D) is also essential but should follow the assessment of health risks.

2. A healthcare provider is delegating client care to assistive personnel. Which of the following tasks should the healthcare provider delegate?

• A. Evaluating healing of an incision
• B. Inserting an NG Tube
• C. Performing a simple dressing change
• D. Changing IV tubing

Correct answer: C

Rationale: The correct task that a healthcare provider should delegate to assistive personnel is performing a simple dressing change. Assistive personnel are trained and competent in performing basic wound care activities like simple dressing changes. Evaluating the healing of an incision requires clinical judgment and assessment skills that are typically performed by licensed healthcare professionals, such as nurses or physicians. Inserting an NG tube and changing IV tubing involve invasive procedures that require specialized training and skills, making them tasks that should be performed by licensed healthcare providers rather than assistive personnel.

3. A client is being taught about dietary management of hypercholesterolemia. Which of the following foods should be suggested to add to the diet?

• A. Avocados
• B. Fried chicken
• C. Whole milk
• D. Bacon

Correct answer: A

Rationale: Avocados are a good choice to suggest adding to the diet of a client with hypercholesterolemia because they are high in healthy fats, particularly monounsaturated fats, which can help manage cholesterol levels. On the other hand, fried chicken, whole milk, and bacon are high in saturated fats and cholesterol, which should be limited in a diet aimed at managing hypercholesterolemia. Therefore, choices B, C, and D are incorrect.

4. A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse?

• A. Diffuse expiratory wheezing
• B. Loose, productive cough
• C. No relief from inhaler
• D. Fever and chills

Correct answer: A

Rationale: During an acute asthma attack, one of the expected assessments by the nurse would be diffuse expiratory wheezing. This occurs due to narrowed airways and increased airflow velocity. Choice B, a loose productive cough, is not typically associated with an asthma attack. Choice C, no relief from inhaler, may indicate ineffective treatment but is not a direct assessment finding related to the physical examination. Choice D, fever and chills, are not typical symptoms of an asthma attack and would not be expected findings during the initial assessment of an acute asthma attack.

5. A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as experiencing chronic pain?

• A. A client who has a broken femur and reports hip pain.
• B. A client who has incisional pain 72 hours following pacemaker insertion.
• C. A client who has food poisoning and reports abdominal cramping.
• D. A client who has episodic back pain following a fall 2 years ago.

Correct answer: D

Rationale: Chronic pain is typically defined as pain lasting longer than 3-6 months or persisting after the expected time for tissue healing. Episodic back pain following a fall 2 years ago fits the criteria for chronic pain. Option A describes acute pain related to a recent fracture. Option B describes acute postoperative pain. Option C describes acute pain associated with an acute condition (food poisoning). Therefore, the correct identification of a client experiencing chronic pain is the one with episodic back pain from a past injury, as it has lasted beyond the normal healing time.

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