Nursing Elites

1. A nurse is planning care for a client who is receiving chemotherapy. Which intervention should the nurse include to manage the client's nausea?

• A. Administer an antiemetic before meals
• B. Provide frequent mouth care
• C. Encourage small, frequent meals
• D. Offer clear liquids

Correct answer: A

Rationale: Administering an antiemetic before meals is a crucial intervention to manage chemotherapy-induced nausea. Antiemetics are medications specifically designed to prevent or relieve nausea and vomiting. By administering the antiemetic before meals, the nurse can help prevent the onset of nausea, allowing the client to eat more comfortably. Providing frequent mouth care (Choice B) is important for maintaining oral hygiene but does not directly address nausea. Encouraging small, frequent meals (Choice C) and offering clear liquids (Choice D) are generally recommended for clients experiencing nausea, but administering an antiemetic is a more targeted approach to specifically address and manage the symptom.

2. A 20-year-old female client tells the nurse that her menstrual periods occur about every 28 days, and her breasts are quite tender when her menstrual flow is heavy. She also states that she performs her breast self-examination (BSE) on the first day of every month. What action should the nurse implement in response to the client's statements?

• A. Remind the client that it is also important to schedule an annual mammogram
• B. Refer the client to a nurse practitioner for an in-depth review of the BSE procedure
• C. Encourage the client to perform BSE 2 to 3 days after the menstrual period ends
• D. Instruct the client to continue with her regular monthly exams as she is doing

Correct answer: C

Rationale: The correct response is to encourage the client to perform breast self-examination (BSE) 2 to 3 days after her menstrual period ends. This timing is important because breasts are least tender during this phase of the menstrual cycle, allowing for a more effective examination. Choice A is incorrect because while scheduling an annual mammogram is important, the immediate concern is the timing of BSE. Choice B is incorrect as the client's BSE practice just needs a slight adjustment in timing, not an in-depth review. Choice D is incorrect as the client should perform BSE when her breasts are least tender for optimal detection of any abnormalities.

3. The nurse is performing a physical assessment of a male client who has chronic renal failure. Which assessment finding is most important for the nurse to report to the healthcare provider?

• A. Client reports difficulty breathing
• B. Client reports shortness of breath when lying flat
• C. Client reports swelling in the feet and ankles
• D. Client reports a metallic taste in the mouth

Correct answer: A

Rationale: In a client with chronic renal failure, difficulty breathing is the most critical finding to report. This symptom may indicate fluid overload or pulmonary edema, which can be life-threatening. Shortness of breath when lying flat (orthopnea) is also concerning but less urgent than difficulty breathing. Swelling in the feet and ankles (edema) is a common finding in renal failure but may not be as immediately critical as difficulty breathing. A metallic taste in the mouth is associated with uremia, a common complication of chronic renal failure, but it is not as urgent as respiratory distress.

4. When obtaining an admission history for a client who is at 9 weeks gestation, the client states, 'I had a miscarriage 2 years ago.' Which information is most important for the nurse to obtain?

• A. How long was your previous pregnancy?
• B. How long did it take for you to become pregnant after your miscarriage?
• C. Was your miscarriage during the first trimester?
• D. Do you have any children now?

Correct answer: A

Rationale: The correct answer is A. Understanding the duration of the previous pregnancy helps assess the client's obstetric history. Choice B focuses on the time it took to conceive after the miscarriage, which is less relevant at this point. Choice C asks about the timing of the miscarriage rather than the duration of the previous pregnancy. Choice D inquires about the current status of having children, which is not directly related to the client's obstetric history.

5. The nurse is caring for a client who is receiving a continuous intravenous infusion of heparin. Which laboratory value should the nurse monitor to evaluate the effectiveness of the therapy?

• A. Platelet count
• B. Prothrombin time (PT)
• C. Partial thromboplastin time (PTT)
• D. Hemoglobin level

Correct answer: C

Rationale: The correct answer is C. Partial thromboplastin time (PTT) is the laboratory value that should be monitored to evaluate the effectiveness of heparin therapy. PTT reflects the intrinsic pathway of coagulation and is specifically sensitive to heparin's anticoagulant effects. Monitoring the PTT helps ensure that the client is within the therapeutic range to prevent clot formation without increasing the risk of bleeding. Choices A, B, and D are incorrect because while they are important laboratory values in other contexts, they are not specifically used to monitor the effectiveness of heparin therapy.

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