Nursing Elites

1. When entering a client’s room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which actions should the nurse implement?

• A. Ignore the behavior and administer the IV antibiotic
• B. Tell the client to stop the inappropriate behavior
• C. Leave the room and close the door quietly
• D. Complete an unusual occurrence report

Correct answer: C

Rationale: The correct action for the nurse in this situation is to leave the room and close the door quietly. This response respects the client's privacy, maintains professionalism, and avoids interrupting the client's personal moment. Choice A is incorrect because ignoring the behavior is not appropriate and may invade the client's privacy further. Choice B is incorrect as it can embarrass the client and the visitor, breaching their privacy and dignity. Choice D is also incorrect as the immediate priority is to respect the client's privacy and address the situation discreetly.

2. Which behavior is most likely to result in a breach of client confidentiality?

• A. Discussing a client’s condition during a teaching conference for nursing staff caring for the client
• B. Two nurses planning a client’s care while having lunch in the hospital cafeteria
• C. Nursing students on the same team discussing their assigned client’s conditions
• D. A registered nurse privately sharing personal feelings about a client with another nurse on the team

Correct answer: B

Rationale: The correct answer is B. Discussing client information in a public area, such as a cafeteria, may lead to breaches of confidentiality. Choice A involves discussing a client's condition in a professional setting, which is not likely to result in a breach as it is for educational purposes. Choice C involves nursing students discussing their assigned client's conditions, which is common in a learning environment and not necessarily a breach of confidentiality. Choice D involves a private conversation between healthcare professionals, which is less likely to result in a breach compared to discussing in a public area like a cafeteria where non-authorized individuals may overhear the conversation.

3. The nurse is caring for a comatose client. Which assessment finding provides the greatest indication that the client has an open airway?

• A. The client has asymmetrical chest expansion
• B. Percussion reveals dullness over the lung area
• C. Bilateral breath sounds can be auscultated
• D. The client has been turned q2h

Correct answer: C

Rationale: The correct answer is C: "Bilateral breath sounds can be auscultated." This finding indicates that air is moving adequately in and out of both lungs, confirming an open airway. Options A, B, and D are incorrect. Asymmetrical chest expansion may indicate lung or chest wall abnormalities, percussion revealing dullness over the lung area may suggest consolidation or fluid, and turning the client q2h is a position change intervention to prevent complications, not a direct assessment of airway patency.

4. A client receiving chemotherapy has severe neutropenia. Which snack is best for the nurse to recommend to the client?

• A. Plain yogurt sweetened with raw honey
• B. Peanuts in the shell, roasted or unroasted
• C. Aged farmer’s cheese with celery sticks
• D. Baked apples topped with dried raisins

Correct answer: A

Rationale: The correct answer is A: Plain yogurt sweetened with raw honey. This option is the best choice for a client with severe neutropenia undergoing chemotherapy because it is less likely to harbor harmful bacteria, which could cause infections due to the weakened immune system. Peanuts in the shell (choice B) may carry a risk of contamination, while aged farmer's cheese with celery sticks (choice C) and baked apples topped with dried raisins (choice D) may not be as safe as plain yogurt for a client with severe neutropenia.

5. The charge nurse is making assignments for clients on an endocrine unit. Which client is best to assign to a new graduate nurse?

• A. A female adult with hyperthyroidism who is returning to the unit after a thyroidectomy
• B. A male adult with Cushing's syndrome who reports a headache and visual disturbances
• C. An older man with Addison's disease who is diaphoretic and has hand tremors
• D. A perimenopausal woman with Graves' disease who is nervous and has exophthalmos

Correct answer: A

Rationale: A new graduate nurse can manage the care of a stable client returning from a thyroidectomy. Choice B is not suitable for a new graduate nurse as it involves complex symptoms of Cushing's syndrome that require more experience and knowledge. Choice C presents a client with acute manifestations of Addison's disease, which may be challenging for a new graduate nurse. Choice D involves a client with Graves' disease experiencing nervousness and exophthalmos, which also require a higher level of expertise to manage effectively.

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