Nursing Elites

1. The client with a diagnosis of chronic heart failure is receiving discharge teaching. Which statement by the client indicates a need for further teaching?

• A. I will weigh myself every day at the same time.
• B. I will call my doctor if my legs swell more.
• C. I will take my water pill only when I feel short of breath.
• D. I will limit the amount of salt in my diet.

Correct answer: C

Rationale: The correct answer is C. Taking water pills (diuretics) only when feeling short of breath is incorrect. Diuretics should be taken regularly as prescribed to help manage fluid retention in chronic heart failure. This statement indicates a need for further teaching as the client needs to understand the importance of consistent medication adherence. Choices A, B, and D demonstrate good understanding of self-care management in heart failure, including daily weight monitoring, prompt reporting of worsening symptoms to the healthcare provider, and dietary sodium restriction, respectively.

2. A post-op nurse has an indwelling catheter in place for gravity drainage. The nurse notes that the client's urine bag has been empty for 2 hours. The first action the nurse should take is to:

• A. Check to see if the tubing is kinked.
• B. Increase the IV fluid rate.
• C. Check the catheter insertion site.
• D. Contact the healthcare provider.

Correct answer: A

Rationale: The correct action for the nurse to take when the urine bag has not filled for 2 hours is to check if the tubing is kinked. Kinks in the tubing can obstruct the flow of urine from the catheter, leading to decreased drainage. Increasing the IV fluid rate is not the appropriate initial action in this situation as the primary concern is with the catheter drainage. Checking the catheter insertion site would be secondary to ensuring proper drainage. Contacting the healthcare provider is not necessary as the issue can often be resolved by checking for simple tubing obstructions first.

3. When is a depressed client at highest risk for attempting suicide?

• A. Immediately after admission, during one-to-one observation
• B. 7 to 14 days after initiation of antidepressant medication and psychotherapy
• C. Following an angry outburst with family
• D. When the client is removed from the security room

Correct answer: B

Rationale: Depressed clients are at the highest risk of attempting suicide 7 to 14 days after starting antidepressant medication and psychotherapy. During this time, they may start to regain energy but still feel hopeless, which can increase the risk of suicidal ideation and behavior. Choices A, C, and D are incorrect because immediate post-admission, after an angry outburst with family, or when removed from a security room are not specific periods known to be associated with the highest risk of suicide in depressed clients.

4. While bathing a patient, the nurse notices movement in the patient's hair. What action should the nurse take?

• A. Use gloves to inspect the hair.
• B. Apply a lindane-based shampoo immediately.
• C. Shave the patient's hair off.
• D. Ignore the movement and continue.

Correct answer: A

Rationale: When a nurse suspects pediculosis capitis (head lice) upon noticing movement in the patient's hair, the correct action is to use gloves to inspect the hair. This protects the nurse from potential self-infestations. Applying a lindane-based shampoo immediately (Choice B) is not the first action, as diagnosis and confirmation are necessary before treatment. Shaving the patient's hair off (Choice C) is an extreme measure and is unnecessary at this stage. Ignoring the movement and continuing (Choice D) is negligent and can lead to the spread of infestation.

5. During a skin assessment, a client expresses concern about skin cancer. What findings should the nurse identify as a potential indication of a skin malignancy?

• A. A mole with an asymmetrical appearance.
• B. A mole with a regular border.
• C. A mole that is the same color throughout.
• D. A mole that is smaller than 6mm in diameter.

Correct answer: A

Rationale: The correct answer is A: A mole with an asymmetrical appearance. Asymmetry is a key characteristic of potential skin malignancy. An asymmetrical mole does not have a uniform shape when divided in half. This irregularity raises suspicion for skin cancer. Choices B, C, and D are incorrect. A mole with a regular border (B) is more likely to be benign. A mole that is the same color throughout (C) is also a feature commonly seen in benign moles. Additionally, a mole smaller than 6mm in diameter (D) is not necessarily indicative of malignancy, as some melanomas can be smaller or larger than this size.

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