Nursing Elites

1. What might be suggested to a client with fibrocystic breasts in an attempt to help relieve symptoms?

• A. Increase intake of high-calcium foods in your diet
• B. Wear a supportive bra during the day and at night
• C. Take over-the-counter pain relievers
• D. Perform regular breast massage

Correct answer: B

Rationale: The correct answer is B: 'Wear a supportive bra during the day and at night.' Wearing a supportive bra is essential for individuals with fibrocystic breasts as it helps relieve discomfort by providing necessary support to reduce strain on breast tissue. Option A is incorrect as high-calcium foods are not directly related to symptom relief in fibrocystic breasts. Option C is not the first-line recommendation and may not address the underlying issue. Option D, performing regular breast massage, is not typically recommended and may not provide significant relief for fibrocystic breast symptoms.

2. The nurse is providing care for a client with advanced liver disease who is experiencing ascites. Which intervention should the nurse implement to help manage the client's fluid volume?

• A. Increase the client's sodium intake
• B. Encourage the client to drink more fluids
• C. Place the client in a supine position
• D. Administer a diuretic as prescribed

Correct answer: D

Rationale: Administering a diuretic as prescribed is the most appropriate intervention to manage fluid volume in a client with ascites due to advanced liver disease. Diuretics help reduce fluid accumulation in the body, including the abdominal cavity where ascites occurs. Increasing sodium intake would worsen fluid retention, and encouraging more fluid intake can exacerbate ascites. Placing the client in a supine position does not directly address the fluid volume issue associated with ascites.

3. The nurse is caring for a client who had a myocardial infarction 6 hours ago. The primary goal of care at this time is to

• A. Limit the effects of tissue damage
• B. Relieve pain and anxiety
• C. Prevent arrhythmias
• D. Reduce anxiety

Correct answer: A

Rationale: The correct answer is A: 'Limit the effects of tissue damage.' After a myocardial infarction, the primary goal of care is to limit the damage to the heart muscle. This includes interventions to improve blood flow, oxygenation, and prevent further complications. Choice B ('Relieve pain and anxiety') is important but secondary to addressing tissue damage. Choice C ('Prevent arrhythmias') is also crucial but falls under the broader goal of limiting tissue damage. Choice D ('Reduce anxiety') is essential for holistic care but is not the primary goal immediately after a myocardial infarction.

4. A client with antisocial personality disorder repeatedly requests a specific nurse be assigned to him and is belligerent when another nurse is assigned. What action should the charge nurse implement?

• A. Remind the client that nurse assignments are not based on patient requests
• B. Assign the nurse requested by the client to avoid further conflict
• C. Tell the client that he can request a different nurse if unhappy
• D. Explain the situation calmly and reinforce the rules regarding nurse assignments

Correct answer: A

Rationale: The correct action for the charge nurse to implement is to remind the client that nurse assignments are not based on patient requests. In this situation, it is essential to establish boundaries and communicate that nurse assignments are made based on clinical decisions, not patient preferences. Option B is incorrect because it compromises the principle of fairness in nurse assignments. Option C is incorrect as it encourages the client's behavior by allowing him to request a different nurse based on personal preferences. Option D is also incorrect as it does not address the issue of patient manipulation and reinforces inappropriate behavior.

5. A client with diabetes mellitus is scheduled for surgery, and their blood glucose level is 280 mg/dL. What is the nurse's priority action?

• A. Administer insulin as prescribed.
• B. Delay surgery until the blood glucose is below 180 mg/dL.
• C. Check the client’s hemoglobin A1C level.
• D. Administer IV fluids to flush excess glucose.

Correct answer: A

Rationale: The correct answer is A: Administer insulin as prescribed. In clients with diabetes, high blood glucose levels can increase the risk of infection and impair healing after surgery. Administering insulin as prescribed helps reduce blood glucose to a safer level before surgery, preventing complications. Choice B is incorrect because delaying surgery without addressing the high blood glucose level does not address the immediate issue. Choice C is incorrect as checking the client's hemoglobin A1C level is not the priority when dealing with acute high blood glucose levels before surgery. Choice D is incorrect as administering IV fluids may help with hydration but does not directly address the high blood glucose level that needs immediate attention.

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