Nursing Elites

1. The client reports nausea and constipation. Which of the following would be the priority nursing action?

• A. Collect a stool sample
• B. Complete an abdominal assessment
• C. Administer an anti-nausea medication
• D. Notify the physician

Correct answer: B

Rationale: The priority nursing action when a client reports symptoms like nausea and constipation is to complete an abdominal assessment. Assessment is crucial as it involves the systematic collection of data to understand the client's condition. By assessing the abdomen, the nurse can gather essential information to make a nursing diagnosis and develop a care plan. Collecting a stool sample (Choice A) may be necessary but comes after the assessment to confirm findings. Administering an anti-nausea medication (Choice C) addresses symptoms but does not address the underlying cause without a thorough assessment. Notifying the physician (Choice D) should come after the assessment to provide a complete picture of the client's condition.

2. A triage nurse has four clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first?

• A. A 2-month-old infant with a history of rolling off the bed and having a bulging fontanelle with crying
• B. A teenager who suffered singed facial hair while camping
• C. An elderly client with complaints of frequent liquid brown-colored stools
• D. A middle-aged client with intermittent pain behind the right scapula

Correct answer: B

Rationale: The correct answer is the teenager who suffered singed facial hair while camping. This client is in the greatest danger with a potential risk of respiratory distress. Singed facial hair indicates exposure to heat or fire in close range, which could have caused serious damage to the interior of the lungs. It's crucial to prioritize this client as the interior lining of the lungs has no nerve fibers, so swelling may not be immediately noticeable. The other choices, while concerning, do not present an immediate life-threatening situation. The infant's condition may be serious but does not pose an immediate danger of respiratory distress. The elderly client's symptoms could indicate gastrointestinal issues, which are important but not as urgent as potential respiratory compromise. The middle-aged client's pain behind the right scapula, while uncomfortable, does not indicate an acute life-threatening condition requiring immediate attention.

3. A patient's urine tests positive for glucose. The doctor asks you to confirm this finding. Which of the following would BEST confirm this finding?

• A. Run the urine on the hand-held glucometer.
• B. Have another MA perform a repeat dipstick test.
• C. Run a Clinitest.
• D. Run an Acetest.

Correct answer: C

Rationale: To confirm glucosuria, the most appropriate method is to run a Clinitest. Clinitest tablets are specifically designed to detect glucose in urine samples. This test is particularly useful when the urine is discolored, making it challenging to accurately assess the color change.\n Choice A, using a hand-held glucometer, is not the standard method for confirming glucose in urine; these devices are primarily used for blood glucose monitoring.\n Choice B, having another Medical Assistant perform a repeat dipstick test, may not provide a more definitive confirmation as dipstick tests can sometimes yield false positives or be less accurate compared to other methods like the Clinitest.\n Choice D, running an Acetest, is used to detect ketones in the urine, not glucose. Ketones are typically associated with conditions like diabetic ketoacidosis, which is different from glucosuria.

4. Which of the following is a fat-soluble vitamin?

• A. Vitamin C
• B. Vitamin D
• C. Vitamin B-6
• D. Riboflavin

Correct answer: B

Rationale: The correct answer is Vitamin D. Fat-soluble vitamins are those that can be stored in the body, allowing excess amounts to be stored for later use. While this storage ability can help prevent deficiencies, it also poses a risk of toxicity. The fat-soluble vitamins are A, E, D, and K. Choice A, Vitamin C, is water-soluble, not fat-soluble. Choice C, Vitamin B-6, and Choice D, Riboflavin, are also water-soluble vitamins and not fat-soluble.

5. The nurse is comparing the concepts of religion and spirituality. Which statement describes an appropriate component of one's spirituality?

• A. Belief in and worship of God or gods
• B. Being closely tied to one's ethnic background
• C. Attendance at a specific church or place of worship
• D. A connection with something larger than oneself and belief in transcendence

Correct answer: D

Rationale: Spirituality refers to a connection with something larger than oneself and a belief in transcendence. The other responses do not apply to spirituality. Choice A, 'Belief in and worship of God or gods,' and choice C, 'Attendance at a specific church or place of worship,' are more aligned with religious practices. Choice B, 'Being closely tied to one's ethnic background,' is not a defining aspect of spirituality or religion as it pertains more to cultural identity rather than spiritual beliefs.

Similar Questions