Nursing Elites

1. The nurse is providing discharge teaching to a client with a new diagnosis of osteoporosis. Which instruction should the nurse include?

• A. Increase dietary intake of calcium-rich foods.
• B. Avoid activities that increase the risk of falls.
• C. Avoid prolonged exposure to sunlight.
• D. Increase intake of vitamin D supplements.

Correct answer: B

Rationale: Avoiding activities that increase the risk of falls (B) is the most crucial instruction for a client with osteoporosis to prevent fractures. Osteoporosis weakens bones, making them more susceptible to fractures from falls. While increasing calcium intake (A) is important for bone health, avoiding falls takes precedence to prevent immediate harm. Avoiding prolonged exposure to sunlight (C) is not directly related to osteoporosis management. Increasing vitamin D supplements (D) is beneficial for bone health, but fall prevention is more critical in this scenario.

2. A client with a history of coronary artery disease (CAD) is admitted with chest pain. Which intervention should the nurse implement first?

• A. Administer sublingual nitroglycerin
• B. Obtain a 12-lead electrocardiogram (ECG)
• C. Apply oxygen via nasal cannula
• D. Initiate continuous cardiac monitoring

Correct answer: C

Rationale: In a client with a history of coronary artery disease (CAD) experiencing chest pain, the priority intervention for the nurse to implement first is to apply oxygen via nasal cannula. Oxygenation is crucial to ensure adequate oxygen supply to the tissues and the heart. This intervention takes precedence over administering sublingual nitroglycerin, obtaining an ECG, or initiating continuous cardiac monitoring. While these interventions are important, ensuring adequate oxygenation is the initial priority in the management of a client with chest pain.

3. After an adult had an indwelling catheter removed, the nurse catheterizes them as ordered and obtains 200 cc of urine. What is the best interpretation of this finding?

• A. Is voiding normally.
• B. Has urinary retention.
• C. Has developed renal failure.
• D. Needs an indwelling catheter.

Correct answer: B

Rationale: The finding of obtaining 200 cc of urine after catheterization indicates urinary retention, as the bladder did not empty completely after the first void. This situation may require further assessment and intervention to address the issue of incomplete bladder emptying. Choice A is incorrect because voiding normally would indicate a larger amount of urine output. Choice C is incorrect as renal failure would typically present with other signs and symptoms. Choice D is incorrect as the presence of urinary retention does not necessarily mean the need for an indwelling catheter immediately.

4. What is the most important instruction for the nurse to provide to a 65-year-old client who attends an adult daycare program, is wheelchair-mobile, and has redness in the sacral area?

• A. Take a vitamin supplement tablet once a day.
• B. Change positions in the chair at least every hour.
• C. Increase daily intake of water or other oral fluids.
• D. Purchase a newer model wheelchair.

Correct answer: B

Rationale: For a client with redness in the sacral area, the most critical instruction is to change positions in the chair at least every hour. This is crucial to prevent pressure ulcers, which can develop due to prolonged pressure on the skin and underlying tissues. Regular position changes help relieve pressure on vulnerable areas, promoting circulation and reducing the risk of skin breakdown and pressure ulcer formation.

5. A seriously ill female client tells the nurse, 'I am so tired and in so much pain! Please help me to die.' Which is the best response for the nurse to provide?

• A. Administer the prescribed maximum dose of pain medication.
• B. Talk with the client about her feelings related to her own death.
• C. Collaborate with the healthcare provider about initiating antidepressant therapy.
• D. Refer the client to the ethics committee of her local healthcare facility.

Correct answer: B

Rationale: The nurse should prioritize addressing the client's emotional needs by engaging in a conversation to understand the underlying feelings behind her statement. By exploring the client's thoughts about death, the nurse can provide appropriate support and interventions tailored to the client's concerns. Rushing to administer pain medication may not address the emotional distress expressed by the client. Initiating antidepressant therapy is not suitable without assessing the client's feelings further. Referring the client to the ethics committee is premature and does not address the immediate emotional needs of the client. Therefore, empathetic communication and assessment of the client's feelings regarding her situation are crucial for providing holistic care.

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