Nursing Elites

1. A client with skin grafts covering full-thickness burns on both arms and legs is scheduled for a dressing change. The client is nervous and requests that the dressing change be skipped this time. What action is most important for the nurse to take?

• A. Explain the importance of regular dressing changes
• B. Administer an anti-anxiety medication
• C. Proceed with the scheduled dressing change
• D. Encourage the client to express any anxieties

Correct answer: A

Rationale: In this situation, the most important action for the nurse to take is to explain the importance of regular dressing changes to the client. By doing so, the nurse can help the client understand the necessity for wound healing and infection prevention. Administering anti-anxiety medication (Choice B) may not address the root cause of the client's anxiety, which is the lack of understanding. Proceeding with the scheduled dressing change (Choice C) without addressing the client's concerns can worsen their anxiety and decrease trust. Encouraging the client to express any anxieties (Choice D) is important but not as crucial as ensuring the client comprehends the rationale behind the dressing change.

2. The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply)

• A. Evaluate the client for sleep disturbances
• B. limit client exercise
• C. Report any client complaint of pain or discomfort
• D. Note and report the client's food and liquid intake during meals and snacks

Correct answer: D

Rationale: Weighing the client and monitoring food and liquid intake are appropriate tasks to delegate to the unlicensed assistive personnel (UAP) when managing a client with Cushing's syndrome. These tasks provide essential information for evaluating the client's condition and response to treatment. Evaluating for sleep disturbances and reporting client complaints of pain or discomfort require a higher level of assessment and interpretation, which should be performed by licensed healthcare providers. Therefore, options A and C are tasks that involve assessment and interpretation beyond the scope of practice for UAP.

3. In a client in her third trimester of pregnancy, an S3 heart sound is auscultated. What intervention should the nurse take?

• A. Notify the healthcare provider
• B. Limit the client’s fluids
• C. Prepare the client for an echocardiogram
• D. Document in the client’s record

Correct answer: D

Rationale: An S3 heart sound can be a normal finding in pregnancy due to increased blood volume and flow. In this scenario, there is no immediate need for further interventions. Documenting this finding in the client's record is essential for tracking the client's health status and ensuring proper follow-up if needed. Notifying the healthcare provider, limiting fluids, or preparing for an echocardiogram is unnecessary as it is likely a physiological finding in pregnancy. These interventions should only be considered if other symptoms suggestive of a cardiac issue are present.

4. A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 mmHg and he admits that he has not been taking the prescribed medication because the drugs make him feel bad. In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?

• A. Stroke secondary to hemorrhage
• B. Acute kidney injury due to glomerular damage
• C. Heart block due to myocardial damage
• D. Blindness secondary to cataracts

Correct answer: A

Rationale: The correct answer is A: Stroke secondary to hemorrhage. Hypertension increases the risk of stroke due to the stress and damage it causes to blood vessels, which can lead to hemorrhage. Choice B is incorrect because acute kidney injury is more commonly associated with chronic uncontrolled hypertension, not acute elevations. Choice C is incorrect as heart block is not a direct consequence of hypertension. Choice D is incorrect as hypertension does not directly cause cataracts leading to blindness.

5. Which instruction is most important for the client who receives a new prescription for risedronate sodium to treat osteoporosis?

• A. Remain upright for 30 minutes after taking the medication
• B. Increase intake of foods rich in vitamin D
• C. Begin a low-impact exercise routine
• D. Take the medication with a full glass of water

Correct answer: A

Rationale: The most important instruction for a client receiving risedronate sodium to treat osteoporosis is to remain upright for 30 minutes after taking the medication. Risedronate sodium can cause esophageal irritation, and staying upright helps prevent this side effect. While increasing vitamin D intake, starting a low-impact exercise routine, and taking the medication with a full glass of water are all beneficial for managing osteoporosis, the immediate need is to prevent esophageal irritation caused by risedronate sodium.

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