Nursing Elites

1. The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?

• A. Has everyone at home already had varicella?
• B. Have the antifungal creams been effective?
• C. Do your family members share combs and brushes?
• D. Do you have any dry patches on your feet and hands?

Correct answer: A

Rationale: The correct answer is A: 'Has everyone at home already had varicella?' Herpes zoster (shingles) is caused by the reactivation of the varicella-zoster virus, the same virus that causes chickenpox. By knowing if others at home had varicella (chickenpox), the nurse can assess the risk of transmission and provide appropriate guidance. Choice B is incorrect because antifungal creams are not effective for herpes zoster, which is a viral infection. Choice C is irrelevant to herpes zoster as it pertains to sharing personal items that may transmit head lice or certain skin infections. Choice D is also unrelated as it focuses on dry patches, not typical manifestations of herpes zoster which presents as a painful rash.

2. A client with deep vein thrombosis (DVT) is being treated with warfarin. Which dietary instruction should the nurse provide?

• A. Avoid foods high in vitamin C
• B. Increase intake of green leafy vegetables
• C. Limit intake of foods high in vitamin K
• D. Avoid dairy products

Correct answer: C

Rationale: The correct answer is C: 'Limit intake of foods high in vitamin K'. Vitamin K can interfere with the effectiveness of warfarin, an anticoagulant medication commonly used to treat conditions like deep vein thrombosis (DVT). Patients on warfarin should maintain a consistent intake of vitamin K-rich foods and be monitored closely. Choices A, B, and D are incorrect because avoiding foods high in vitamin C, increasing intake of green leafy vegetables, and avoiding dairy products are not essential dietary instructions for a client on warfarin therapy for DVT.

3. Which nursing intervention promotes achievement of the goal 'optimal mobility' for a client who had a total hip replacement 8 hours ago?

• A. Encourage the client to use an abductor pillow when ambulating.
• B. Teach the client to perform leg exercises in bed.
• C. Assist the client to sit at the edge of the bed.
• D. Assist the client to turn while an abductor pillow is between the legs.

Correct answer: D

Rationale: Assisting the client to turn while an abductor pillow is between the legs is the correct intervention to promote optimal mobility for a client who had a total hip replacement 8 hours ago. Using an abductor pillow helps maintain hip alignment and prevents dislocation, which are crucial considerations in the early postoperative period. Encouraging the client to use an abductor pillow when turning is more beneficial compared to the other options: teaching leg exercises in bed, encouraging the use of a walker when ambulating, or assisting the client to sit at the edge of the bed, as these interventions may not directly address the specific needs of a client after a total hip replacement.

4. The nurse is teaching a client how to collect a sputum specimen. Which steps should the nurse instruct the client to follow when collecting sputum?

• A. Breathe deeply, followed by swallowing.
• B. Breathe deeply, followed by spitting into a cup.
• C. Breathe deeply, followed by coughing up the sputum.
• D. Breathe deeply, followed by clearing the throat.

Correct answer: C

Rationale: The correct answer is to instruct the client to breathe deeply followed by coughing up the sputum. This method ensures that the specimen is collected from the lower respiratory tract and is not contaminated by saliva. Choice A (swallowing) does not result in sputum collection, while choice B (spitting into a cup) may lead to saliva contamination. Choice D (clearing the throat) is not an effective way to collect sputum as it may involve getting rid of saliva, not sputum.

5. A client with chronic kidney disease is receiving epoetin alfa. Which laboratory value should the nurse monitor to determine the effectiveness of the treatment?

• A. Blood urea nitrogen (BUN)
• B. Serum creatinine
• C. Hemoglobin and hematocrit
• D. Serum potassium

Correct answer: C

Rationale: The correct answer is C: Hemoglobin and hematocrit. Epoetin alfa is a medication that stimulates red blood cell production, so monitoring hemoglobin and hematocrit levels is essential to assess its effectiveness. These values reflect the oxygen-carrying capacity of the blood and can indicate if the treatment is improving anemia related to chronic kidney disease. Choices A, B, and D are incorrect. Blood urea nitrogen (BUN) and serum creatinine are indicators of kidney function, while serum potassium levels are monitored due to electrolyte imbalances commonly seen in kidney disease, but they do not directly reflect the effectiveness of epoetin alfa.

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