Nursing Elites

1. During a change-of-shift assessment, a nurse is evaluating four clients. Which finding should the nurse report to the provider first?

• A. Client with cystic fibrosis who has a thick productive cough and reports thirst
• B. Client with gastroenteritis who is lethargic and confused
• C. Client with diabetes mellitus who has a morning fasting glucose of 185 mg/dL
• D. Client with sickle cell anemia who reports pain 15 minutes after receiving analgesic

Correct answer: B

Rationale: The nurse should report the client with gastroenteritis who is lethargic and confused to the provider first. Lethargy and confusion in a client with gastroenteritis may indicate dehydration or electrolyte imbalance, both of which can be life-threatening if not addressed promptly. The other options indicate important assessments that require intervention but do not pose an immediate life-threatening risk compared to the client with signs of dehydration and electrolyte imbalance.

2. A client is being educated about using an intrauterine device (IUD) for contraception. Which of the following client statements indicate an understanding of the teaching?

• A. I will need to have the IUD replaced each year.
• B. I will need to apply a spermicide prior to intercourse.
• C. I should expect my periods to stop while I have the IUD.
• D. I should check for the string each month after menstruation.

Correct answer: D

Rationale: The correct answer is D because the client should check for the string each month after menstruation to ensure the IUD is in place. This practice helps in identifying any displacement of the IUD. Choices A, B, and C are incorrect. A is incorrect because IUDs have different durations depending on the type, not all require yearly replacement. B is incorrect because IUDs do not require spermicide for effectiveness. C is incorrect because while some individuals may experience changes in their menstrual patterns, it is not guaranteed that periods will stop while using an IUD.

3. A nurse is providing discharge teaching for a client who has COPD about nutrition. Which of the following instructions should the nurse include?

• A. Eat three large meals daily
• B. Consume high-calorie, high-protein foods
• C. Limit caffeinated drinks to two per day
• D. Drink fluids between meals

Correct answer: B

Rationale: The correct answer is B: 'Consume high-calorie, high-protein foods.' Clients with COPD often have increased energy needs due to the work of breathing. Consuming high-calorie, high-protein foods can help provide the necessary energy and prevent weight loss. Choice A is incorrect because eating three large meals daily may lead to increased shortness of breath due to a full stomach. Choice C is incorrect because limiting caffeinated drinks is important, but the recommendation should focus on reducing intake, not specifying a number. Choice D is incorrect because drinking fluids during mealtime can lead to early satiety, making it difficult for the client to consume enough calories.

4. A nurse is admitting a client who has meningococcal meningitis. What should the nurse do first?

• A. Initiate droplet precautions
• B. Start intravenous antibiotics
• C. Perform a complete assessment
• D. Notify the healthcare provider

Correct answer: A

Rationale: The first priority when admitting a client with meningococcal meningitis is to initiate droplet precautions. This is essential to prevent the transmission of the infection to others, as meningococcal meningitis is highly contagious through respiratory droplets. Starting intravenous antibiotics or performing a complete assessment can follow, but the immediate concern is to implement infection control measures. Notifying the healthcare provider should also be done but is not the first action to take in this situation.

5. A healthcare professional is assessing a client with deep vein thrombosis (DVT). Which of the following interventions should the healthcare professional include in the plan of care?

• A. Apply ice packs to the affected extremity.
• B. Encourage ambulation every hour.
• C. Elevate the affected leg when in bed.
• D. Massage the affected area to improve circulation.

Correct answer: C

Rationale: Elevating the affected leg is a crucial intervention in the care of a client with deep vein thrombosis (DVT). This position helps reduce swelling and promotes venous return, which can alleviate symptoms associated with DVT. Applying ice packs (Choice A) may worsen the condition by causing vasoconstriction. Encouraging ambulation (Choice B) can dislodge the clot and lead to fatal complications. Massaging the affected area (Choice D) can also dislodge the clot and is contraindicated in DVT.

Similar Questions