Nursing Elites

1. When performing an admission assessment of a client diagnosed with a brain tumor, which question is most important for the nurse to ask the client?

• A. When did your symptoms first begin?
• B. Can you describe the pain and how it feels?
• C. Do you have any changes in vision?
• D. Have you experienced any seizures?

Correct answer: D

Rationale: The correct answer is D. When assessing a client diagnosed with a brain tumor, asking about seizures is crucial because they can be a common symptom associated with brain tumors. Seizures in this context could provide valuable information regarding the progression and impact of the brain tumor on the client's neurological status. Choices A, B, and C are important questions in a general assessment, but when specifically focusing on a client with a brain tumor, inquiring about seizures takes priority due to its direct relevance to the condition.

2. What instruction is most important for the nurse to provide a female client who has just been diagnosed with trichomoniasis?

• A. Avoid douching
• B. Treat sexual partner(s) concurrently
• C. Avoid using moist washcloths when bathing
• D. Postpone becoming pregnant until the infection is treated

Correct answer: B

Rationale: The most important instruction for a female client diagnosed with trichomoniasis is to treat sexual partner(s) concurrently. This is crucial to prevent reinfection and the spread of the infection. Choice A, avoiding douching, is generally recommended for vaginal health but is not the most critical instruction in this case. Choice C, avoiding moist washcloths when bathing, is not directly related to the transmission or treatment of trichomoniasis. Choice D, postponing pregnancy until the infection is treated, is important but treating sexual partners concurrently takes precedence to prevent reinfection.

3. Which action should the nurse include in the plan of care for a client who is receiving acyclovir (Zovirax) IV for the treatment of herpes zoster (shingles)?

• A. Initiate cardiac telemetry monitoring
• B. Maintain continuous pulse oximetry
• C. Perform capillary glucose measurements
• D. Monitor serum creatinine levels

Correct answer: D

Rationale: The correct answer is to monitor serum creatinine levels. Acyclovir can potentially impact kidney function, making it essential to monitor serum creatinine levels to assess renal function. Option A, initiating cardiac telemetry monitoring, is not directly related to acyclovir administration for herpes zoster. Option B, maintaining continuous pulse oximetry, is more relevant in assessing respiratory status rather than monitoring for acyclovir-related side effects. Option C, performing capillary glucose measurements, is not directly associated with acyclovir therapy for herpes zoster.

4. When the nurse enters the room to change the dressing of a male client with cancer, he asks, 'Have you ever been with someone when they died?' What is the nurse's best response to him?

• A. Yes, I have. Do you have some questions about dying?
• B. Several times. Now, let's get your dressing changed.
• C. A few times. It was peaceful and there was no pain.
• D. Yes, but you're doing great. Are you concerned about dying?

Correct answer: A

Rationale: The correct response is to acknowledge the client's question and open the door for further discussion by asking if they have questions about dying. This approach allows the nurse to address the client's concerns and fears, promoting open communication and providing emotional support. Choices B and C do not encourage further dialogue about the client's feelings and concerns regarding death. Choice D briefly acknowledges the question but does not actively invite the client to express their thoughts and emotions regarding dying.

5. A male client admitted three days ago with respiratory failure is intubated, and 40% oxygen per facemask is initiated. Currently, his temperature is 99°F, capillary refill is less than 4 seconds, and respiratory effort is within normal limits. What outcome should the nurse evaluate to measure for successful extubation?

• A. Exhibits adequate tissue perfusion
• B. Remains free of injury
• C. Remains free of infection
• D. Maintains effective breathing pattern

Correct answer: D

Rationale: Successful extubation relies on the patient's ability to maintain an effective breathing pattern. This indicates that the patient can adequately oxygenate and ventilate without the need for mechanical support. Monitoring tissue perfusion, preventing infection, and ensuring safety are important but not directly related to the immediate criteria for successful extubation. Tissue perfusion, injury prevention, and infection control are crucial aspects of overall patient care but are not the primary factors to consider when evaluating readiness for extubation.

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