Nursing Elites

1. A nurse is preparing to administer a medication to a client. The client states, 'I'm sick of all these medications, and I'm not taking any more today!' Which of the following actions should the nurse take?

• A. Ask the client to discuss their feelings
• B. Explain the importance of the medications
• C. Document the refusal and withhold the medication
• D. Inform the client of the possible consequences of refusal

Correct answer: D

Rationale: When a client refuses medication, the nurse should inform the client of the possible consequences of refusal. This action helps the client understand the risks associated with not taking the medication. Asking the client to discuss their feelings (choice A) is important but should follow after informing them of the consequences. Explaining the importance of the medications (choice B) might not address the immediate concern of the client. Documenting the refusal and withholding the medication (choice C) should be done after informing the client of the consequences and attempting to address their concerns.

2. Which of the following interventions is most appropriate for a client with left-leg weakness who is learning to use a cane?

• A. Maintain two points of support on the floor at all times
• B. Use the cane on the weak side of the body
• C. Advance the cane and the strong leg simultaneously
• D. Advance the cane 30 to 45 cm (12-18 in) with each step

Correct answer: A

Rationale: The most appropriate intervention for a client with left-leg weakness learning to use a cane is to maintain two points of support on the floor at all times. This ensures stability and helps distribute weight evenly between the legs, reducing the risk of falls. Using the cane on the weak side of the body (Choice B) may not provide adequate support. Advancing the cane and the strong leg simultaneously (Choice C) can lead to imbalance and increases the risk of falls. Advancing the cane too far with each step (Choice D) can also compromise balance and stability.

3. A healthcare professional is collecting data from a client who has iron deficiency anemia. Which of the following findings should the healthcare professional expect?

• A. Increased energy
• B. Easy bruising
• C. Pale conjunctiva
• D. Weight gain

Correct answer: C

Rationale: Pale conjunctiva is a common sign of iron deficiency anemia due to reduced hemoglobin levels. This results in decreased oxygen-carrying capacity, leading to tissue hypoxia and pallor. 'Increased energy' (choice A) is not typically associated with iron deficiency anemia, as fatigue and weakness are common symptoms. 'Easy bruising' (choice B) is more characteristic of platelet disorders or vitamin deficiencies rather than iron deficiency anemia. 'Weight gain' (choice D) is not a typical finding in iron deficiency anemia; in fact, weight loss is more common due to decreased appetite and overall weakness.

4. A nurse is caring for a client with a pressure ulcer. Which of the following interventions is most appropriate?

• A. Administer a protein supplement
• B. Increase protein intake in the client's diet
• C. Increase IV fluid intake to improve hydration
• D. Cleanse the wound from the center outwards

Correct answer: D

Rationale: The correct answer is to cleanse the wound from the center outwards. This technique helps prevent infection and promotes healing by ensuring that any contaminants are moved away from the center of the wound. Administering a protein supplement (choice A) or increasing protein intake in the client's diet (choice B) may be beneficial for overall healing but are not the most appropriate interventions specifically for wound care. Increasing IV fluid intake (choice C) is important for hydration but is not the most appropriate intervention for managing a pressure ulcer.

5. A client diagnosed with gout is receiving dietary instruction from a nurse. What dietary advice should be provided?

• A. Limit intake of fresh fruits and uncooked vegetables
• B. Limit intake of red meat and shellfish
• C. Limit intake of dairy products
• D. Increase intake of leafy greens

Correct answer: B

Rationale: The correct answer is to limit the intake of red meat and shellfish. These foods are high in purines, which can increase uric acid levels and trigger gout flare-ups. Fresh fruits, uncooked vegetables, dairy products, and leafy greens are generally not associated with exacerbating gout symptoms and do not need to be significantly restricted in the diet of someone with gout.

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