Nursing Elites

1. An 85-year-old client complains of generalized muscle aches and pains. What should be the nurse's first action?

• A. Assess the severity and location of the pain
• B. Obtain an order for an analgesic
• C. Reassure the client that this is not unusual for his age
• D. Encourage the client to increase activity

Correct answer: A

Rationale: The correct answer is to assess the severity and location of the pain. This is crucial because understanding the nature of the pain will guide the nurse in developing an appropriate pain management plan. Choice B is incorrect because administering analgesics should come after assessing the pain to ensure the right medication is given. Choice C is incorrect because dismissing the pain as a normal part of aging without proper assessment could overlook underlying issues. Choice D is incorrect as increasing activity without understanding the cause of pain may exacerbate the client's condition.

2. A healthcare provider is collecting data from a client who is receiving chemotherapy and is showing manifestations of malnutrition. Which of the following indicates a Vitamin C deficiency?

• A. Dry, red conjunctiva
• B. Swollen, bleeding gums
• C. Inflammation of the tongue
• D. Pale, brittle nails

Correct answer: B

Rationale: Swollen, bleeding gums are a classic sign of scurvy, which is caused by a deficiency in Vitamin C. Dry, red conjunctiva, inflammation of the tongue, and pale, brittle nails are not specific manifestations of Vitamin C deficiency, making them incorrect choices.

3. While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degrees Celsius). The appropriate nursing intervention is to

• A. Call the health care provider immediately
• B. Administer acetaminophen as ordered as this is normal at this time
• C. Send blood, urine, and sputum for culture
• D. Increase the client's fluid intake

Correct answer: B

Rationale: In this scenario, the nurse should administer acetaminophen as ordered because a slight fever is normal after an MI. This intervention can help manage the fever unless other complications are present. Calling the health care provider immediately is not necessary for a slight fever post-MI. Sending blood, urine, and sputum for culture is not indicated solely based on a slight fever without other symptoms or signs of infection. Increasing fluid intake may be beneficial for various reasons but is not the priority in this situation where managing the fever with acetaminophen is appropriate.

4. A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first?

• A. Ask the client to cough sputum into a container
• B. Have the client take several deep breaths
• C. Provide an appropriate specimen container
• D. Assist with oral hygiene

Correct answer: D

Rationale: Assisting with oral hygiene is the essential initial step before collecting a sputum specimen for acid-fast bacillus (AFB) to prevent contamination of the sample. Ensuring the client's mouth is clean reduces the risk of introducing unwanted bacteria into the specimen. Asking the client to cough sputum into a container, having the client take deep breaths, and providing a specimen container are important steps in the specimen collection process, but they should follow ensuring proper oral hygiene.

5. The nurse is caring for a 7-year-old with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate?

• A. Decreased carbohydrates and fat
• B. Decreased sodium and potassium
• C. Increased potassium and protein
• D. Increased sodium and fluids

Correct answer: B

Rationale: The correct answer is 'Decreased sodium and potassium.' In acute glomerulonephritis, managing edema and oliguria is crucial. Reducing sodium and potassium intake helps achieve this by decreasing fluid retention and workload on the kidneys. Choice A, 'Decreased carbohydrates and fat,' is not directly related to managing AGN. Choice C, 'Increased potassium and protein,' is incorrect as increasing potassium can be harmful in kidney conditions. Choice D, 'Increased sodium and fluids,' is also incorrect as it can exacerbate edema and hypertension in AGN.

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