Nursing Elites

1. The doctor orders 2% nitroglycerin ointment in a 1-inch dose every 12 hours. Proper application of nitroglycerin ointment includes:

• A. Rotating application sites
• B. Limiting applications to the chest
• C. Rubbing it into the skin
• D. Covering it with a thin paper dressing

Correct answer: A

Rationale: Proper application of nitroglycerin ointment involves rotating application sites to prevent skin irritation. It should be applied to the back and upper arms, not restricted to the chest, making option B incorrect. Rubbing it into the skin, as indicated in option C, is not recommended for nitroglycerin ointment as it can lead to faster absorption and potential side effects. The correct way is to cover it with a thin paper dressing, not gauze as mentioned in option D, to ensure proper absorption and prevent the medication from evaporating too quickly.

2. In a brief treatment program, what is a realistic short-term goal for a client who was raped?

• A. Identify all psychosocial problems
• B. Eliminate the client's enticing behaviors
• C. Resolve feelings of trauma and fear
• D. Verbalize feelings about the event

Correct answer: D

Rationale: A realistic short-term goal for a client who was raped and is receiving a brief treatment program is for the client to verbalize feelings about the event. This goal focuses on helping the client express their emotions, which can be a crucial step in the healing process. Options A and C are incorrect because a brief treatment program is not typically aimed at identifying or resolving all psychosocial problems or deep-rooted trauma and fear. Option B is also incorrect as the goal is to support the client in processing their feelings rather than focusing on behaviors.

3. When supporting a family who has just experienced a sudden and unexpected death, the nurse needs to know:

• A. that survivors have greater emotional turmoil and shock than when death is expected.
• B. that survivors have less emotional turmoil and shock than when death is expected.
• C. that survivors have the same emotional turmoil and shock as when death is expected.
• D. that survivors have little emotional turmoil and shock because they were not there.

Correct answer: A

Rationale: The correct answer is that survivors have greater emotional turmoil and shock than when death is expected. Sudden death produces more emotional turmoil and shock in survivors compared to gradual, expected death. Survivors of sudden death do not have the opportunity to engage in anticipatory grief. The unexpectedness of sudden death is the most disturbing and unbalancing factor, leading to heightened emotional turmoil and shock. Choice B is incorrect as survivors of sudden death experience more emotional turmoil and shock. Choice C is incorrect because sudden death brings about a different level of emotional turmoil and shock. Choice D is incorrect as survivors of sudden and unexpected death still go through significant emotional distress.

4. The nurse observes bilateral bruises on the arms of an elderly client in a long-term care facility. Which of the following questions should the nurse ask this client?

• A. "How did you get those bruises?"?
• B. "Did someone grab you by your arms?"?
• C. "Do you fall often?"?
• D. "What did you bump against?"?

Correct answer: B

Rationale: When addressing suspected abuse, it is crucial to ask direct questions to determine the cause of injuries. Choice B is the most appropriate as it directly inquires about the possibility of someone grabbing the client's arms, which could indicate abuse. This question can help uncover potential abuse and provide necessary intervention. Choices A, C, and D are less direct and may not elicit the critical information needed to address abuse effectively. Clients often hesitate to report abuse due to feelings of shame and fear of retaliation, making a direct approach essential in such situations.

5. The licensed practical nurse assigned to the postpartum unit is preparing to administer Rhogam to a postpartum client. Which woman is not a candidate for RhoGam?

• A. A gravida IV para 3 that is Rh negative with an Rh-positive baby
• B. A gravida I para 1 that is Rh negative with an Rh-positive baby
• C. A gravida II para 0 that is Rh negative admitted after a stillbirth delivery
• D. A gravida IV para 2 that is Rh negative with an Rh-negative baby

Correct answer: D

Rationale: The mothers in answers A, B, and C all require RhoGam as they are Rh negative with an Rh-positive baby or have experienced a stillbirth delivery, making them candidates for RhoGam injection. The mother in answer D is the only one who does not require Rhogam because she is Rh negative with an Rh-negative baby, eliminating the need for RhoGam administration.

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