Nursing Elites

1. When the client finds antiembolism stockings uncomfortably tight, what is the nurse's best action?

• A. Remove the stockings for an hour to relieve the pressure
• B. Pull the stockings down so that they are not constricting
• C. Measure the client's calf to ensure that they are the correct size
• D. Teach the client the purpose of wearing the stockings

Correct answer: D

Rationale: The correct action for the nurse to take when a client finds antiembolism stockings uncomfortably tight is to teach the client the purpose of wearing the stockings. This educates the client on the importance of the stockings in preventing blood clots and encourages compliance. Removing the stockings or pulling them down may compromise their effectiveness. Measuring the client's calf size is not necessary in this situation as the discomfort is due to tightness, not incorrect sizing.

2. A client who has a head injury is transported to the emergency department. Which assessment does the emergency department nurse perform immediately?

• A. Pupil response
• B. Motor function
• C. Respiratory status
• D. Short-term memory

Correct answer: C

Rationale: In a client with a head injury, assessing the respiratory status is the priority as airway and breathing are essential for life. Immediate attention to respiratory status is crucial to ensure adequate oxygenation. While assessing pupil response and motor function are also important in head injuries, ensuring the client's ability to breathe takes precedence. Short-term memory assessment is not a priority in the emergent phase of care for a client with a head injury.

3. A female client with deteriorating neurologic function states, "I am worried I will not be able to care for my young children."? How does the nurse respond?

• A. "Caring for your children is a priority. You may not want to ask for help, but you have to."?
• B. "Our community has resources that may help you with some household tasks so you have energy to care for your children."?
• C. "You seem distressed. Would you like to talk to a psychologist about adjusting to your changing status?"?
• D. "Give me more information about what worries you, so we can see if we can do something to make adjustments."?

Correct answer: D

Rationale: When a client expresses worry about not being able to care for her children due to deteriorating neurologic function, the most appropriate response from the nurse is to gather more information from the client. This open-ended approach allows the nurse to better understand the client's specific concerns and needs, leading to tailored interventions and support. Choice A is dismissive and may make the client feel guilty for needing help. Choice B focuses on external resources without addressing the client's worries directly. Choice C suggests a psychological referral without exploring the client's concerns further. Therefore, the correct response is to gather more information to provide personalized support.

4. While taking the history of an older adult client, which assessment finding alerts the nurse that the client needs further assessment for fluid or electrolyte imbalance?

• A. "I am often cold and need to wear a sweater."?
• B. "I seem to urinate more when I drink coffee."?
• C. "In the summer, I feel thirsty more often."?
• D. "My rings seem to be tighter this week."?

Correct answer: D

Rationale: The correct answer is 'My rings seem to be tighter this week.' This assessment finding indicates possible fluid retention, which can be a sign of fluid or electrolyte imbalance in an older adult. Choices A, B, and C do not specifically point towards fluid or electrolyte imbalance. Feeling cold, increased urination with coffee consumption, and feeling thirsty in the summer are not direct indicators of fluid or electrolyte imbalance in this context.

5. The nurse teaches a client who is newly diagnosed with coronary artery disease. Which instruction does the nurse include to minimize complications of this disease?

• A. "Rest is the best medicine at this time. Do not start an exercise program."?
• B. "You are a man; therefore, there is nothing you can do to minimize your risks."?
• C. "You should talk to your provider about medications to help you quit smoking."?
• D. "Decreasing the carbohydrates in your diet will help you lose weight."?

Correct answer: C

Rationale: The correct answer is to advise the client to talk to their provider about medications to help quit smoking. Smoking is a major risk factor for coronary artery disease, and quitting smoking can significantly reduce the risk of complications. Choice A is incorrect because exercise is beneficial for managing coronary artery disease, but should be started gradually and under guidance. Choice B is incorrect and inappropriate as it undermines the client's ability to take control of their health. Choice D is incorrect because while a balanced diet is important, specifically targeting carbohydrates alone may not be the most effective or healthy approach for managing coronary artery disease.

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