Nursing Elites

1. The unlicensed assistive personnel (UAP) reports to the nurse that a client refused to bathe for the third consecutive day. What action is best for the nurse to take?

• A. Ask the client why the bath was refused
• B. Ask family members to encourage the client to bathe
• C. Explain the importance of good hygiene to the client
• D. Reschedule the bath for the following day

Correct answer: A

Rationale: The correct action for the nurse to take is to ask the client why the bath was refused. Understanding the client's reasons for refusal can guide appropriate interventions, respecting client autonomy while addressing any underlying issues. Choice B is not the best course of action as involving family members may not address the client's specific concerns. Choice C, while important, may not directly address the immediate refusal to bathe. Choice D does not address the underlying reasons for the refusal and may not lead to a resolution.

2. A client is diagnosed with Angina Pectoris. Which factor in the client's history is likely related to the anginal pain?

• A. Smokes one pack of cigarettes daily
• B. Drinks two beers daily
• C. Works in a job that requires exposure to the sun
• D. Eats while lying in bed

Correct answer: A

Rationale: The correct answer is A: 'Smokes one pack of cigarettes daily.' Smoking is a major risk factor for angina and other cardiovascular diseases due to its impact on blood vessels. Choice B, 'Drinks two beers daily,' is not directly associated with angina pectoris. While excessive alcohol consumption can contribute to heart problems, it is not a primary risk factor for angina. Choice C, 'Works in a job that requires exposure to the sun,' is not typically related to angina pectoris. Sun exposure is more closely linked to skin-related conditions. Choice D, 'Eats while lying in bed,' is also not a common risk factor for angina. While certain eating habits can impact heart health, this specific behavior is not directly associated with angina pectoris.

3. When teaching a diabetic client about foot care, what information is most important?

• A. Inspect feet daily
• B. Wear cotton socks
• C. Use lukewarm water to wash feet
• D. Cut nails straight across

Correct answer: A

Rationale: Inspecting feet daily is crucial for diabetic clients as it can help prevent complications like infections and ulcers. This practice allows for early detection of any foot issues, enabling timely intervention. While wearing cotton socks (choice B) is beneficial as they absorb moisture and reduce the risk of fungal infections, it is not as critical as daily foot inspection. Using lukewarm water to wash feet (choice C) is important to prevent burns or skin damage in diabetic clients with decreased sensation, but it is not as crucial as daily foot inspection. Cutting nails straight across (choice D) is essential to prevent ingrown nails, but it is not the most important information when educating diabetic clients about foot care.

4. The healthcare provider is caring for a client with a chest tube following a pneumothorax. Which assessment finding should be reported to the healthcare provider immediately?

• A. Continuous bubbling in the water seal chamber
• B. Absence of drainage in the collection chamber
• C. Tidaling in the water seal chamber
• D. Presence of subcutaneous emphysema around the insertion site

Correct answer: A

Rationale: Continuous bubbling in the water seal chamber should be reported to the healthcare provider immediately. This finding may indicate an air leak, which can compromise the effectiveness of the chest tube in re-expanding the lung. Absence of drainage in the collection chamber (choice B) may signify that the chest tube is blocked, but it does not pose an immediate threat to the client's condition. Tidaling in the water seal chamber (choice C) is an expected finding and indicates proper functioning of the chest tube system. Presence of subcutaneous emphysema around the insertion site (choice D) suggests air leakage but is not as urgent as continuous bubbling in the water seal chamber.

5. A client with a diagnosis of bipolar disorder is taking lithium. What is the most important information the nurse should provide?

• A. Take the medication on an empty stomach
• B. Monitor sodium intake
• C. Report any signs of weight gain
• D. Avoid excessive caffeine intake

Correct answer: B

Rationale: The correct answer is B. Sodium levels can affect lithium levels in the body, so it is crucial to monitor sodium intake to prevent toxicity or subtherapeutic levels. Lithium is typically taken on an empty stomach to enhance absorption, making choice A more accurate than the original 'Take the medication with food.' Reporting weight gain, as mentioned in choice C, is important for monitoring side effects but is not as critical as ensuring proper lithium levels through sodium intake monitoring. Choice D, avoiding excessive caffeine intake, is not a priority concern directly related to lithium therapy.

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