Nursing Elites

1. The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. What action should the nurse take?

• A. Collect the blood sample
• B. Assess radial pulse volume
• C. Apply pressure to the site
• D. Select another finger

Correct answer: A

Rationale: When the nurse observes that the distal tip of the client's finger is reddened and engorged after milking, it indicates adequate blood flow. At this point, the appropriate action is to collect the blood sample for glucose level testing. Assessing radial pulse volume (Choice B) is unrelated to the situation and not necessary. Applying pressure to the site (Choice C) may disrupt the blood sample collection process. Selecting another finger (Choice D) is not warranted as the engorgement indicates sufficient blood flow for sampling.

2. A client reports new onset hearing loss bilaterally after taking a medication with known ototoxic effects. Which type of hearing loss should the nurse suspect?

• A. Conductive
• B. Sensorineural
• C. Mixed
• D. Central

Correct answer: B

Rationale: The correct answer is B: Sensorineural. Ototoxic medications can lead to sensorineural hearing loss by affecting the inner ear or auditory nerve. Conductive hearing loss is related to issues in the middle or outer ear, not typically caused by ototoxic medications. Mixed hearing loss is a combination of conductive and sensorineural components. Central hearing loss is related to the central nervous system, not commonly caused by ototoxic medications. Therefore, in this case, the nurse should suspect sensorineural hearing loss.

3. A client with AIDS has impaired gas exchange from a respiratory infection. Which assessment finding warrants immediate intervention by the nurse?

• A. Elevated temperature
• B. Generalized weakness
• C. Diminished lung sounds
• D. Pain when swallowing

Correct answer: D

Rationale: In a client with AIDS and impaired gas exchange from a respiratory infection, pain when swallowing can indicate esophageal involvement, such as esophagitis or an esophageal infection like candidiasis. These conditions can significantly impact the client's ability to take in nutrition and medications, leading to complications like dehydration and malnutrition. Therefore, immediate intervention is required to address the underlying cause and prevent further complications. Elevated temperature (choice A) may indicate infection but does not directly address the impaired gas exchange. Generalized weakness (choice B) and diminished lung sounds (choice C) are concerning but do not directly relate to the immediate need for intervention in the context of esophageal involvement in a client with impaired gas exchange.

4. Which intervention should the nurse include in the plan of care for a client who has a chest tube due to hemothorax?

• A. Keep the arm and shoulder of the affected side immobile at all times.
• B. Encourage the client to breathe deeply and cough at frequent intervals.
• C. Maintain the pleura vac slightly above the chest level.
• D. Ensure there is no fluctuation in the water seal.

Correct answer: B

Rationale: Encouraging deep breathing and coughing is vital for a client with a chest tube due to hemothorax as it helps prevent atelectasis and promotes lung expansion. Keeping the arm and shoulder immobile (Choice A) is not necessary for chest tube management. Maintaining the pleura vac slightly above the chest level (Choice C) is incorrect as the pleura vac should be kept below the chest level to facilitate drainage. Ensuring no fluctuation in the water seal (Choice D) is important, but it is not the priority intervention when compared to promoting lung expansion through deep breathing and coughing.

5. A client with a new colostomy is concerned about odor. What is the best advice the nurse can provide?

• A. Avoid high-fiber foods
• B. Use an odor-proof pouch
• C. Decrease fluid intake
• D. Increase dairy products in the diet

Correct answer: B

Rationale: The best advice the nurse can provide to a client concerned about odor from a new colostomy is to use an odor-proof pouch. This option helps control odors effectively by containing and masking any unpleasant smells. Avoiding high-fiber foods (Choice A) is not the best advice as fiber is essential for bowel health, and decreasing fluid intake (Choice C) can lead to dehydration and other complications. Increasing dairy products in the diet (Choice D) is not directly related to controlling odors from a colostomy.

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