Nursing Elites

1. A nurse is collecting data from a client who is experiencing a situational crisis following the loss of a job. The client states, 'I don't think I can go through this again.' Which of the following actions is the nurse's priority?

• A. Determine if the client is experiencing psychotic thinking
• B. Determine the client's support system
• C. Ask how the client copes with stress
• D. Assess the client's vital signs

Correct answer: A

Rationale: The priority is to determine if the client is experiencing psychotic thinking or suicidal ideation. In this situation, the nurse needs to assess if the client is having distorted thoughts or losing touch with reality, which could pose an immediate risk to the client's safety. While determining the client's support system, asking how the client copes with stress, and assessing vital signs are important aspects of care, they are not the priority when there is a concern about potential psychotic thinking or suicidal ideation.

2. Which nursing action is a priority when caring for a client with heart failure?

• A. Encourage the client to drink fluids frequently
• B. Weigh the client daily to monitor fluid balance
• C. Increase fluid intake to prevent dehydration
• D. Limit the client's sodium intake

Correct answer: B

Rationale: Weighing the client daily is a priority action when caring for a client with heart failure because it helps monitor fluid balance. This monitoring is essential in managing heart failure as it allows healthcare providers to assess for signs of fluid retention or depletion, which are crucial in adjusting treatment plans. Encouraging the client to drink fluids frequently (Choice A) may worsen fluid overload in heart failure patients. Increasing fluid intake (Choice C) can exacerbate fluid retention. While limiting sodium intake (Choice D) is important in heart failure management, monitoring fluid balance through daily weighing takes precedence as a priority nursing action.

3. A nurse on an acute unit has received a change of shift report for 4 clients. Which of the following clients should the nurse assess first?

• A. A client who is 1 hr postoperative and has hypoactive bowel sounds.
• B. A client who has a fractured left tibia and pallor in the affected extremity.
• C. A client who had a cardiac catheterization 3 hr ago and has 3+ pedal pulses.
• D. A client who has an elevated AST level following the administration of azithromycin.

Correct answer: B

Rationale: The correct answer is B because pallor in an extremity after a fracture could indicate compromised circulation, making it a priority for assessment. Choice A is not the priority as hypoactive bowel sounds in a client 1 hr postoperative, while concerning, do not indicate a life-threatening condition. Choice C, a client who had a cardiac catheterization 3 hr ago and has 3+ pedal pulses, indicates good perfusion and does not require immediate attention. Choice D, a client with an elevated AST level following the administration of azithromycin, may require further assessment but is not as urgent as the client with potential compromised circulation in choice B.

4. What is the nurse's role in preoperative patient care?

• A. Provide patient education and ensure NPO status
• B. Ensure that informed consent is obtained
• C. Obtain the patient's health history
• D. Confirm the patient's surgical site

Correct answer: A

Rationale: The nurse plays a crucial role in preoperative patient care by providing education and ensuring NPO (nothing by mouth) status. This helps prepare the patient for surgery by ensuring they understand the procedure, what to expect, and also by following necessary preoperative fasting guidelines. While obtaining the patient's health history (choice C) is important for overall patient assessment, it is typically done during the preoperative assessment but does not specifically pertain to the nurse's role. Ensuring informed consent (choice B) is primarily the responsibility of the healthcare provider performing the procedure. Confirming the patient's surgical site (choice D) is usually the responsibility of the surgical team and is done immediately before the surgery to prevent errors.

5. A nurse is teaching a client who is at risk for developing osteoporosis. Which of the following recommendations should the nurse make?

• A. Walk for at least 30 minutes each day
• B. Avoid sunlight exposure
• C. Take vitamin B12 supplements
• D. Increase calcium intake to 1,500 mg per day

Correct answer: D

Rationale: The correct answer is to increase calcium intake to 1,500 mg per day. Adequate calcium intake is essential for maintaining bone density and reducing the risk of osteoporosis. Walking for at least 30 minutes each day is beneficial for overall health but is not as directly related to osteoporosis prevention as calcium intake. Sunlight exposure is important for vitamin D synthesis, which is necessary for calcium absorption, so avoiding sunlight exposure would not be recommended. Vitamin B12 supplements are not directly related to bone health or osteoporosis prevention, so this would not be the most appropriate recommendation.

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