Nursing Elites

1. A nurse questions a medication prescription as too extreme in light of the client’s advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles?

• A. Fidelity
• B. Autonomy
• C. Justice
• D. Nonmaleficence

Correct answer: D

Rationale: The correct answer is D, Nonmaleficence. Nonmaleficence refers to the principle of 'do no harm.' In this scenario, questioning a potentially harmful prescription for a client with advanced age and unstable status aligns with the principle of nonmaleficence, as the nurse is advocating for the client's safety and well-being. Choice A, Fidelity, refers to being faithful and keeping promises, which is not directly related to the situation described. Choice B, Autonomy, pertains to respecting a patient's right to make their own decisions, which is not the focus of the nurse questioning the prescription. Choice C, Justice, involves fairness and equal treatment, which is not the primary ethical principle at play in this situation.

2. A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor?

• A. Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back
• B. Pinch the skin on the back of the hand and observe for elasticity
• C. Assess the skin turgor on the abdomen by pinching the skin
• D. Check the skin turgor by pressing on the forearm and observing the rebound

Correct answer: A

Rationale: To assess skin turgor, the nurse should grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back. This method is preferred for older adults and in cases of significant fluid imbalance. Option B is incorrect as assessing skin turgor on the back of the hand is not the standard assessment site for skin turgor. Option C is incorrect as the abdomen is not the typical area for assessing skin turgor; the chest under the clavicle is a more accurate site. Option D is incorrect as pressing on the forearm is not the appropriate site for evaluating skin turgor; the chest under the clavicle is the recommended location for this assessment.

3. A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The client who has heat stroke will have which of the following?

• A. Hypotension
• B. Bradycardia
• C. Clammy skin
• D. Bradypnea

Correct answer: A

Rationale: The correct answer is A: Hypotension. Heat stroke is characterized by elevated body temperature, which can lead to hypotension (low blood pressure) due to dehydration and vasodilation. Bradycardia (slow heart rate) and clammy skin are not typical findings in heat stroke. Bradypnea (slow breathing) is also not a common feature of heat stroke. Therefore, hypotension is the most likely cardiovascular manifestation seen in a client with heat stroke.

4. A client with herpes zoster asks the nurse about using complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies?

• A. Biofeedback
• B. Aloe
• C. Feverfew
• D. Acupuncture

Correct answer: D

Rationale: Acupuncture is contraindicated for clients with herpes zoster due to the risk of introducing an open portal on the skin, which can increase the risk of infection. This therapy involves inserting needles into specific points on the body, potentially causing skin trauma and providing a route for the virus to spread. Biofeedback, aloe, and feverfew are not contraindicated for clients with herpes zoster and can be considered for pain management in this condition. Biofeedback involves using electronic devices to help individuals learn to control physiological processes, aloe is a plant known for its skin-soothing properties, and feverfew is an herb that has been used for pain relief.

5. A healthcare professional is preparing to admit a client suspected of having pulmonary tuberculosis. Which of the following actions should the healthcare professional plan to perform first?

• A. Implement airborne precautions.
• B. Obtain a sputum culture.
• C. Administer antituberculosis medications.
• D. Recommend a screening test for close contacts.

Correct answer: A

Rationale: The initial priority when admitting a client suspected of having pulmonary tuberculosis is to implement airborne precautions to prevent the spread of the disease. Airborne precautions include wearing a mask and placing the client in a negative pressure room. Obtaining a sputum culture is essential for confirming the diagnosis, but ensuring infection control measures come first to protect others. Administering antituberculosis medications is important but should be initiated after implementing necessary precautions. Recommending a screening test for close contacts is relevant but is a secondary concern compared to immediate infection control measures.

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