Nursing Elites

1. An adolescent tells the school nurse that she is pregnant. Her last menstrual period was 4 months ago. She has not received any medical care. She smokes but denies any other substance use. What is the priority nursing action?

• A. notify her parents
• B. refer her for prenatal care
• C. teach breastfeeding methods
• D. offer nutritional instructions

Correct answer: B

Rationale: The correct answer is to refer her for prenatal care. Prenatal care is essential to monitor the health of both the mother and the fetus during pregnancy. While notifying her parents may be important for support and involvement, the priority is ensuring the adolescent receives medical care. Teaching breastfeeding methods and offering nutritional instructions are important but are not the immediate priority in this situation where prenatal care is urgently needed.

2. A client with a history of myocardial infarction is prescribed aspirin therapy. Which instruction should the nurse include in the client's teaching plan?

• A. Take aspirin with food.
• B. Take aspirin at the same time every day.
• C. Avoid taking aspirin with alcohol.
• D. Discontinue aspirin if you experience ringing in your ears.

Correct answer: C

Rationale: The correct instruction for the nurse to include in the client's teaching plan is to avoid taking aspirin with alcohol. Combining aspirin with alcohol can increase the risk of gastrointestinal bleeding and other complications. Taking aspirin with food helps reduce stomach upset, but it is not the most crucial instruction in this scenario. While taking aspirin at the same time every day can help with consistency, it is not as critical as avoiding alcohol. Discontinuing aspirin if experiencing ringing in the ears is important to address potential side effects, but it is not directly related to preventing complications when combining with alcohol.

3. During a home visit, a nurse observes an older client who is attempting to ambulate to the bathroom and notes that the client is unsteady and holds onto the furniture while refusing any assistance. Which action should the nurse implement?

• A. determine home navigational safety hazards
• B. maintain the client's privacy while in the bathroom
• C. recommend that the client obtain a walker
• D. encourage the client to obtain a medical alert device

Correct answer: A

Rationale: The correct action for the nurse to implement is to determine home navigational safety hazards. In this scenario, the client is unsteady and holds onto furniture while refusing assistance, indicating a risk of falls. By identifying and addressing home safety hazards, the nurse can help prevent potential accidents. Maintaining privacy in the bathroom (Choice B) is important but not the priority in this situation. Recommending a walker (Choice C) or a medical alert device (Choice D) may be appropriate interventions later but addressing home safety hazards is the immediate concern.

4. A client with chronic kidney disease is experiencing pruritus. Which intervention should the nurse include in the plan of care?

• A. Administer antihistamines as prescribed.
• B. Apply moisturizing lotion to the skin.
• C. Use cool water for bathing.
• D. Encourage a high-protein diet.

Correct answer: A

Rationale: Correct. Administering antihistamines as prescribed is the appropriate intervention for a client with chronic kidney disease experiencing pruritus. Antihistamines can help reduce pruritus by blocking histamine receptors, which are often prescribed for such clients. Choice B, applying moisturizing lotion, may help with dry skin but will not directly address pruritus. Choice C, using cool water for bathing, may provide some relief but does not target the underlying cause of pruritus. Choice D, encouraging a high-protein diet, is not directly related to managing pruritus in chronic kidney disease.

5. A community health nurse is evaluating the effectiveness of a recent smoking cessation program. Which outcome indicates success?

• A. increased attendance at support group meetings
• B. reduced number of cigarettes smoked per day
• C. higher sales of nicotine replacement products
• D. lower relapse rate among participants

Correct answer: D

Rationale: The correct answer is D: lower relapse rate among participants. A lower relapse rate indicates that participants are successfully quitting smoking and maintaining their cessation, which is the ultimate goal of a smoking cessation program. Increased attendance at support group meetings (choice A) may demonstrate engagement but does not necessarily indicate successful smoking cessation. Similarly, higher sales of nicotine replacement products (choice C) may reflect increased product usage but not necessarily successful smoking cessation. While reducing the number of cigarettes smoked per day (choice B) is a positive change, it does not guarantee successful smoking cessation or long-term abstinence.

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