Nursing Elites

1. An older male client with a history of diabetes mellitus, chronic gout, and osteoarthritis comes to the clinic with a bag of medication bottles. Which intervention should the nurse implement first?

• A. Identify pills in the bag
• B. Review the client's medication schedule
• C. Assess the client's symptoms
• D. Educate the client about proper medication usage

Correct answer: A

Rationale: The correct answer is to identify pills in the bag first. This is essential to ensure the client is taking the correct medications and to prevent any potential medication errors. Reviewing the client's medication schedule (choice B) can come after identifying the pills to cross-reference the medications. Assessing the client's symptoms (choice C) is important but should follow identifying the medications. Educating the client about proper medication usage (choice D) is crucial but should be done after confirming the medications in the bag.

2. A school nurse is called to the soccer field because a child has a nosebleed (epistaxis). In what position should the nurse place the child?

• A. Sitting up and leaning forward
• B. Lying flat with legs elevated
• C. Lying on the side with the head slightly raised
• D. Sitting up and tilting the head back

Correct answer: A

Rationale: The child with a nosebleed (epistaxis) should be placed in a sitting position, leaning forward, to prevent blood from flowing down the throat. This position helps to control the bleeding and prevents the child from swallowing blood, which can cause nausea or vomiting. Choice B is incorrect because elevating the legs is not recommended for nosebleeds. Choice C is incorrect because lying on the side with the head slightly raised is not the optimal position for managing a nosebleed. Choice D is incorrect because tilting the head back can lead to blood flowing down the throat and potentially cause aspiration.

3. A male client with diabetes mellitus type 2, who is taking pioglitazone PO daily, reports to the nurse the recent onset of nausea, accompanied by dark-colored urine, and a yellowish cast to his skin. What instructions should the nurse provide?

• A. Seek immediate medical assistance to evaluate the cause of these symptoms.
• B. Discontinue the medication and follow up with a healthcare provider.
• C. Increase fluid intake and monitor urine color.
• D. Continue taking the medication and report any changes.

Correct answer: A

Rationale: The correct answer is A: 'Seek immediate medical assistance to evaluate the cause of these symptoms.' The symptoms described by the client, including nausea, dark-colored urine, and yellowish skin, are indicative of possible liver toxicity, a serious side effect of pioglitazone. Therefore, immediate medical evaluation is necessary to assess the severity of the condition and prevent further complications. Choices B, C, and D are incorrect: B advises discontinuing the medication without seeking immediate medical assistance, which could delay necessary treatment; C focuses solely on increasing fluid intake and monitoring urine color, overlooking the urgency of the situation; and D suggests continuing the medication when prompt evaluation is crucial in this scenario.

4. The nurse is reinforcing home care instructions with a client who is being discharged following a transurethral resection of the prostate (TURP). Which intervention is most important for the nurse to include in the client teaching?

• A. Avoid strenuous activity for 6 weeks.
• B. Report fresh blood in the urine.
• C. Take acetaminophen for a fever over 101°F.
• D. Consume 6 to 8 glasses of water daily.

Correct answer: B

Rationale: Reporting fresh blood in the urine is crucial as it may indicate postoperative complications requiring immediate attention. This symptom can be a sign of bleeding, infection, or other issues that need prompt medical evaluation. Avoiding strenuous activity for 6 weeks is important but not as urgent as reporting fresh blood. Taking acetaminophen for a fever over 101°F is relevant but addressing fresh blood in the urine takes precedence. Consuming an adequate amount of water daily is beneficial but not as critical as recognizing and reporting signs of potential complications.

5. When obtaining a rectal temperature with an electronic thermometer, which action is most important for the nurse to perform?

• A. Hold the thermometer in place.
• B. Place the disposable pad under the buttocks.
• C. Instruct the client to breathe deeply.
• D. Return the probe to the charger.

Correct answer: A

Rationale: When obtaining a rectal temperature with an electronic thermometer, holding the thermometer in place is crucial. This action ensures accurate temperature measurement and prevents injury to the client. Option B, placing a disposable pad under the buttocks, is not the most important action; it may enhance comfort but does not impact the accuracy of the temperature reading. Option C, instructing the client to breathe deeply, is irrelevant to obtaining a rectal temperature. Option D, returning the probe to the charger, is an incorrect action after temperature measurement.

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