Nursing Elites

1. The nurse is planning care for a client with end-stage lung cancer. The client expresses concern about ongoing pain management. Which nursing action is most appropriate to include in the plan of care?

• A. Consult the healthcare provider for recommendations on pain management
• B. Schedule the client for physical therapy to manage pain
• C. Recommend the client attend a support group for cancer patients
• D. Suggest alternative therapies like acupuncture or massage

Correct answer: A

Rationale: Consulting the healthcare provider for recommendations on pain management is the most appropriate action. The healthcare provider can assess the client's pain, prescribe appropriate medications, and adjust the pain management plan as needed. In end-stage cancer, managing pain often requires pharmacological interventions that the healthcare provider can best provide. Physical therapy (choice B) may not be the primary intervention for pain management in end-stage cancer. While attending a support group (choice C) can provide emotional support, it does not directly address the client's pain management concerns. Suggesting alternative therapies (choice D) is not the initial step; consulting the healthcare provider should come first to ensure a comprehensive and tailored pain management plan.

2. A client with diabetes mellitus tells the nurse that she uses cranberry juice to help prevent urinary tract infection. What instruction should the nurse provide?

• A. Ensure to drink sugar-free cranberry juice
• B. Drinking cranberry juice does not prevent infection
• C. Cranberries do not affect insulin levels
• D. Excessive cranberry juice consumption can lead to constipation

Correct answer: B

Rationale: The correct answer is B: Drinking cranberry juice does not prevent urinary tract infections and should not be relied upon as a preventive measure. While cranberry juice is often associated with preventing UTIs, there is limited scientific evidence to support this claim. Choice A is incorrect because the sugar content in cranberry juice is not the main concern when discussing its role in preventing UTIs. Choice C is incorrect as there is no significant evidence to suggest cranberries affecting insulin levels. Choice D is incorrect as constipation is not a typical side effect of consuming cranberry juice; however, excessive consumption may lead to gastrointestinal discomfort.

3. An adult client presents to the clinic with large draining ulcers on both lower legs that are characteristic of Kaposi’s Sarcoma lesions. The client is accompanied by two family members. What action should the nurse take?

• A. Obtain a blood sample to determine if the client is HIV positive
• B. Send the family to the waiting area while conducting a head-to-toe assessment
• C. Complete a head-to-toe assessment to identify other signs of HIV
• D. Ask the family members to wear gloves when touching the client

Correct answer: C

Rationale: In this scenario, the most appropriate action for the nurse to take is to complete a head-to-toe assessment to identify other signs of HIV. Kaposi’s Sarcoma is commonly associated with HIV infection, and conducting a comprehensive assessment can provide crucial information on potential signs and symptoms related to HIV. This information is essential for providing appropriate care and treatment. Option A is not the priority at this moment, as the focus should be on assessing the client comprehensively first. Sending the family members away (Option B) may not be necessary if they are not interfering with the assessment process. While infection control is important, asking the family members to wear gloves (Option D) is not the most critical action to take in this situation.

4. After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication?

• A. Ask the client about gastrointestinal pain
• B. Measure the client’s fluid intake and output
• C. Monitor the client’s serum electrolyte levels
• D. Auscultate for bowel sounds in all quadrants

Correct answer: A

Rationale: The correct answer is A: Ask the client about gastrointestinal pain. The effectiveness of a proton pump inhibitor (PPI) is best evaluated by assessing the relief of gastrointestinal symptoms, such as heartburn, acid reflux, or stomach pain. These medications work by reducing the production of stomach acid, so improvement in these symptoms indicates the effectiveness of the PPI. Choices B, C, and D are incorrect because they do not directly reflect the effectiveness of a PPI. Measuring fluid intake and output, monitoring serum electrolyte levels, and auscultating for bowel sounds are important for assessing hydration status, electrolyte balance, and gastrointestinal motility, respectively. However, they are not specific to evaluating PPI effectiveness.

5. A female client with borderline personality disorder is being discharged today. During morning rounds, the client complains about the aloofness of the night shift nurse and expresses joy to see the nurse on duty. Which response is best for the nurse to provide to this client’s dichotomous tendency?

• A. I am glad you like me. Which nurse was acting aloof to you?
• B. Tomorrow I will talk to that nurse about how you were treated last night.
• C. What did the night nurse do that makes you think she is aloof?
• D. I am happy that you are getting better and will be able to go home.

Correct answer: A

Rationale: Choice A is the best response as it acknowledges the client's feelings while exploring their concerns. By asking which nurse was acting aloof, the nurse shows understanding and allows the client to express their feelings further. This response validates the client's emotions and fosters a therapeutic relationship. Choice B focuses on a future action without addressing the immediate concern at hand. Choice C seeks clarification on the night nurse's behavior, which is a good approach but lacks the personal touch of Choice A. Choice D shifts the focus away from the client's current feelings and concerns, missing the opportunity to address the dichotomous thinking displayed by the client.

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