Nursing Elites

1. The nurse in a community health clinic is interviewing a female client who has three children. The client tells the nurse that she has a new man in her life, with whom she is having a sexual relationship, and that they both smoke cigarettes. Which information is most important for the nurse to provide this client?

• A. Oral contraceptives should be started to prevent an unwanted pregnancy
• B. Children are more prone to upper respiratory infections if exposed to smoke at home
• C. Cigarette smoking increases the risk for peptic ulcers and emphysema
• D. A diaphragm and condom provide effective contraception when used together

Correct answer: D

Rationale: The most important information for the nurse to provide the client in this situation is that using both a diaphragm and a condom together provides effective contraception and also protects against sexually transmitted diseases (STDs). While oral contraceptives can help prevent unwanted pregnancies, using a barrier method like a diaphragm and a condom is crucial in this scenario where the client is engaging in a new sexual relationship. Choice B is important information but is not the top priority in this context. Choice C, although relevant, does not address the immediate concern of contraception and STD prevention. Therefore, the correct answer is D.

2. Which action should the nurse include in the plan of care for a client who is receiving acyclovir (Zovirax) IV for the treatment of herpes zoster (shingles)?

• A. Initiate cardiac telemetry monitoring
• B. Maintain continuous pulse oximetry
• C. Perform capillary glucose measurements
• D. Monitor serum creatinine levels

Correct answer: D

Rationale: The correct answer is to monitor serum creatinine levels. Acyclovir can potentially impact kidney function, making it essential to monitor serum creatinine levels to assess renal function. Option A, initiating cardiac telemetry monitoring, is not directly related to acyclovir administration for herpes zoster. Option B, maintaining continuous pulse oximetry, is more relevant in assessing respiratory status rather than monitoring for acyclovir-related side effects. Option C, performing capillary glucose measurements, is not directly associated with acyclovir therapy for herpes zoster.

3. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 4 liters per minute via nasal cannula. The client becomes lethargic and confused. What action should the nurse take first?

• A. Decrease the oxygen flow rate
• B. Increase the oxygen flow rate
• C. Encourage the client to cough and deep breathe
• D. Monitor the client's oxygen saturation level

Correct answer: A

Rationale: In this scenario, the priority action for the nurse is to decrease the oxygen flow rate. Clients with COPD are sensitive to high levels of oxygen and can develop oxygen toxicity, leading to symptoms like lethargy and confusion. Decreasing the oxygen flow rate helps prevent this complication. Increasing the oxygen flow rate would worsen the client's condition. Encouraging coughing and deep breathing may not address the immediate issue of oxygen toxicity. While monitoring the client's oxygen saturation level is important, taking action to address the oxygen toxicity by decreasing the flow rate is the priority in this situation.

4. The nurse is preparing to administer a unit of packed red blood cells (PRBCs) to a client. Which action is most important for the nurse to take?

• A. Verify the client's blood type
• B. Ensure the PRBCs are warm
• C. Check the client's vital signs
• D. Obtain the client's consent

Correct answer: A

Rationale: Verifying the client's blood type is crucial before administering PRBCs to ensure compatibility and prevent transfusion reactions. Checking the client's blood type is essential in blood transfusions. Ensuring the PRBCs are warm is not a priority as the temperature should be within a specific range regardless of the client's preference. Checking the client's vital signs is important but not as crucial as verifying the blood type before a blood transfusion. Obtaining the client's consent is important for any procedure but does not directly impact the safety and success of administering PRBCs.

5. The nurse is assessing a client who is 2 days post-op following abdominal surgery. The client reports feeling something 'give way' in the incision site and there is a small amount of bowel protruding from the wound. What action should the nurse take first?

• A. Apply a sterile saline dressing to the wound
• B. Notify the healthcare provider
• C. Administer pain medication
• D. Cover the wound with an abdominal binder

Correct answer: A

Rationale: In this scenario, the nurse should first apply a sterile saline dressing to the wound. This action helps prevent infection and keeps the wound moist, which is crucial in promoting healing. Option B, notifying the healthcare provider, is important but should come after providing immediate wound care. Option C, administering pain medication, is not the priority when there is a small amount of bowel protruding from the wound. Option D, covering the wound with an abdominal binder, is not appropriate for this situation as it does not address the protruding bowel and potential risk for infection.

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