Nursing Elites

1. What action should the nurse take after a client produces the first of a series of sputum samples for cytology?

• A. Ensure the client remains NPO until all samples are collected
• B. Transport the sputum container to the laboratory in a biohazard bag
• C. Discard the initial sample and document the time it was obtained
• D. Document the time the client last ate or drank on the laboratory slip

Correct answer: B

Rationale: The correct action for the nurse to take after a client produces the first of a series of sputum samples for cytology is to transport the sputum container to the laboratory in a biohazard bag. This is important to ensure proper handling and prevent contamination of the sample. Choice A is incorrect because there is no need to keep the client NPO until all samples are collected. Choice C is incorrect as the initial sample should not be discarded but rather transported to the laboratory. Choice D is also incorrect as documenting the time the client last ate or drank is not directly relevant to the immediate action needed for the sputum sample.

2. A client with rheumatoid arthritis reports a new onset of increasing fatigue. What intervention should the nurse implement first?

• A. Assist the client in conserving energy during daily activities
• B. Explain to the client that this could be a side effect of the medication
• C. Assess the client for pallor
• D. Encourage the client to maintain a balanced diet and hydration

Correct answer: C

Rationale: The correct first intervention for a client with rheumatoid arthritis reporting increasing fatigue is to assess the client for pallor. Fatigue can be a sign of anemia or other complications; assessing for pallor can help determine if anemia is the cause. Option A is incorrect as it does not address the underlying cause of fatigue. Option B assumes the cause without further assessment. Option D is important for overall health but assessing for pallor takes precedence to identify immediate issues related to fatigue.

3. A client is admitted with severe dehydration. What is the most important assessment finding for the nurse to monitor?

• A. Changes in mental status
• B. Urine output and color
• C. Blood pressure and heart rate
• D. Skin turgor

Correct answer: A

Rationale: Changes in mental status are crucial to monitor in a client with severe dehydration. Altered mental status, such as confusion or lethargy, can indicate severe dehydration and potential complications like electrolyte imbalances affecting the brain. Monitoring urine output and color (choice B) is essential but may not provide immediate signs of severe dehydration. While monitoring blood pressure and heart rate (choice C) is important, changes in mental status take precedence as they can indicate more critical conditions. Skin turgor (choice D) is a valuable assessment for dehydration, but changes in mental status take priority due to their direct correlation with severe dehydration.

4. A woman with an anxiety disorder calls her obstetrician’s office and tells the nurse of increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman?

• A. Describe the safety of certain antianxiety medications during breastfeeding
• B. Encourage her to consider stress-relieving alternatives, such as deep breathing exercises
• C. Inform her that some antianxiety medications are safe to take while breastfeeding
• D. Explain that anxiety is a common response for the mother of a 3-week-old

Correct answer: C

Rationale: The correct answer is C. Some antianxiety medications are considered safe for use while breastfeeding, and the nurse should provide this information to alleviate the woman's concerns. Choice A has been corrected to focus on the safety of certain antianxiety medications during breastfeeding, which is more accurate. Choice B suggests stress-relieving alternatives, which may help but do not address the need for antianxiety medication if required. Choice D is incorrect because it minimizes the woman's concerns by dismissing her increased anxiety as a normal response.

5. The nurse is assigned to care for four surgical clients. After receiving report, which client should the nurse see first?

• A. An older client receiving packed RBCs on the third day postoperatively for colon resection
• B. An older client with continuous bladder irrigation who is 2 days postoperatively for bladder surgery
• C. An adult one day postoperatively from laparoscopic cholecystectomy requesting pain medication
• D. An adult in Buck’s traction, scheduled for hip arthroplasty within the next 12 hours

Correct answer: B

Rationale: The correct answer is B because the client with continuous bladder irrigation post-bladder surgery is at risk for complications like infection or bleeding. This client requires immediate attention to assess for any signs of complications such as urinary retention, hemorrhage, or infection. Choices A, C, and D have less urgent needs compared to a client with continuous bladder irrigation, which requires priority assessment.

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