Nursing Elites

1. When documenting assessment data, which statement should the nurse record in the narrative nursing notes?

• A. Client appears anxious.
• B. Client's skin is warm and dry.
• C. S1 murmur auscultated in supine position.
• D. Client is resting quietly.

Correct answer: C

Rationale: The correct answer is C. When documenting assessment data in the narrative nursing notes, it is essential to include objective findings that are specific, clear, and descriptive. 'S1 murmur auscultated in supine position' provides a precise and objective assessment finding that can aid in accurately documenting the client's condition. Choices A, B, and D are more subjective statements that lack the specificity and clarity required for detailed documentation. 'Client appears anxious' and 'Client is resting quietly' are subjective observations, while 'Client's skin is warm and dry' is an objective finding but may not be as significant or relevant for comprehensive documentation as the auscultated murmur.

2. A client with a history of myocardial infarction is prescribed aspirin therapy. Which instruction should the nurse include in the client's teaching plan?

• A. Take aspirin with food.
• B. Take aspirin at the same time every day.
• C. Avoid taking aspirin with alcohol.
• D. Discontinue aspirin if you experience ringing in your ears.

Correct answer: C

Rationale: The correct instruction for the nurse to include in the client's teaching plan is to avoid taking aspirin with alcohol. Combining aspirin with alcohol can increase the risk of gastrointestinal bleeding and other complications. Taking aspirin with food helps reduce stomach upset, but it is not the most crucial instruction in this scenario. While taking aspirin at the same time every day can help with consistency, it is not as critical as avoiding alcohol. Discontinuing aspirin if experiencing ringing in the ears is important to address potential side effects, but it is not directly related to preventing complications when combining with alcohol.

3. A community health nurse is addressing the issue of domestic violence in the community. Which intervention should the nurse implement first?

• A. establishing a support group for survivors of domestic violence
• B. developing educational materials on recognizing signs of abuse
• C. partnering with local law enforcement to increase awareness
• D. conducting a community needs assessment to identify resources

Correct answer: D

Rationale: Conducting a community needs assessment is the most appropriate initial intervention when addressing domestic violence in the community. This step helps the nurse identify existing resources, gaps, and specific needs of the community related to domestic violence. By understanding the community's needs through a needs assessment, the nurse can tailor subsequent interventions effectively. Option A, establishing a support group, may be beneficial later but should not be the first step. Developing educational materials (Option B) and partnering with law enforcement (Option C) are important strategies; however, without understanding the community's specific needs through a needs assessment, the interventions may not be as targeted or effective.

4. During a 2-week postoperative follow-up home visit, a female client who had gastric bypass surgery exhibits abdominal tenderness, shoulder pain, and describes feelings of malaise. Her vital signs are: T 101.8, BP 100/50, HR 104, and RR 18. Which action should the RN take?

• A. have the client transported via ambulance to the hospital
• B. recheck the client's vital signs in 30 minutes
• C. instruct the client to drive to the hospital for admission
• D. assess the client's current symptoms

Correct answer: A

Rationale: The client is presenting with signs of a potential postoperative complication, such as fever, low blood pressure, and tachycardia, which could indicate sepsis or another serious issue. These symptoms require immediate hospital evaluation and management. Option B of rechecking vital signs in 30 minutes could delay crucial intervention in a potentially life-threatening situation. Option C is unsafe as the client should not drive herself due to her condition. Option D is vague and does not address the urgency of the situation.

5. The nurse identifies a client's needs and formulates the nursing problem of 'Imbalance nutrition: Less than body requirements, related to mental impairment and decreased intake, as evidenced by increasing confusion and weight loss of more than 30 pounds over the last 6 months.' Which short-term goal is best for this client?

• A. Eat 50% of six small meals each day by the end of the week.
• B. Gain 5 pounds by the end of the month.
• C. Have increased caloric intake.
• D. Show improved nutritional status.

Correct answer: A

Rationale: The correct short-term goal for the client in this scenario is option A: 'Eat 50% of six small meals each day by the end of the week.' This goal is specific, measurable, and time-bound, which aligns with the SMART criteria for goal setting in nursing care. It addresses the client's nutritional needs directly, focusing on increasing meal frequency to meet body requirements and counteract weight loss. Option B, 'Gain 5 pounds by the end of the month,' is not as suitable as it lacks specificity and a short-term timeline, making it less achievable within the immediate care plan. Option C, 'Have increased caloric intake,' is vague and does not provide a measurable target for the client to work towards. Option D, 'Show improved nutritional status,' is a broad goal that lacks the specificity needed for effective short-term goal setting in nursing care. Therefore, option A is the most appropriate choice for this client's short-term goal.

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