Nursing Elites

1. A community health nurse is assessing an adolescent who is pregnant. Which of the following assessments is the nurse's priority?

• A. Social relationships with peers.
• B. Plans for attending school while pregnant.
• C. Eligibility for Medicaid.
• D. Understanding of infant care.

Correct answer: D

Rationale: The correct answer is D: Understanding of infant care. When assessing a pregnant adolescent, the priority is to ensure that she has the necessary knowledge and skills to care for her newborn. This assessment is crucial in promoting the health and well-being of both the adolescent mother and her baby. Option A, social relationships with peers, though important, is not the priority during this assessment. Option B, plans for attending school while pregnant, is also important but does not take precedence over ensuring the adolescent's understanding of infant care. Option C, eligibility for Medicaid, is important for accessing healthcare services but is not the priority assessment in this scenario.

2. A nurse is assessing a client who has a urinary tract infection and is receiving ciprofloxacin. Which of the following findings should the nurse report to the provider?

• A. Dry mouth.
• B. Photosensitivity.
• C. Headache.
• D. Urinary retention.

Correct answer: B

Rationale: The correct answer is B: Photosensitivity. Ciprofloxacin can cause photosensitivity, making the client more sensitive to sunlight. It is essential for the nurse to report this finding to the provider so that appropriate measures can be taken to prevent skin damage. Dry mouth, headache, and urinary retention are not typically associated with ciprofloxacin use and do not require immediate reporting to the provider in this scenario.

3. A nurse is caring for a client who is receiving enteral nutrition via a nasogastric tube. Which of the following actions should the nurse take to reduce the risk of aspiration?

• A. Position the client supine during feedings.
• B. Administer the feedings over 10 minutes.
• C. Elevate the head of the bed during feedings.
• D. Place the client in a lateral position after feedings.

Correct answer: C

Rationale: The correct action to reduce the risk of aspiration in clients receiving enteral feedings is to elevate the head of the bed during feedings. This position helps prevent regurgitation and aspiration of the feeding. Positioning the client supine (Choice A) increases the risk of aspiration as it promotes reflux. Administering feedings over 10 minutes (Choice B) does not directly reduce the risk of aspiration. Placing the client in a lateral position after feedings (Choice D) does not address the risk of aspiration during the feeding process.

4. A nurse is planning care for a client who has a history of falls. Which of the following actions should the nurse include in the plan of care?

• A. Keep all four side rails up.
• B. Ensure the client's bed is in the lowest position.
• C. Use nonskid footwear while ambulating.
• D. Place a bedside commode close to the client's bed.

Correct answer: C

Rationale: The correct answer is C: 'Use nonskid footwear while ambulating.' This action is crucial in preventing falls in clients with a history of falls as it provides better traction and stability while walking. Choice A, 'Keep all four side rails up,' is not recommended as it can lead to client restraint and is not a fall prevention strategy. Choice B, 'Ensure the client's bed is in the lowest position,' is important for preventing injuries from falls out of bed but does not directly address fall prevention during ambulation. Choice D, 'Place a bedside commode close to the client's bed,' is a good practice for toileting safety but does not specifically address preventing falls while walking.

5. A client with hypertension is receiving discharge teaching from a nurse on managing blood pressure at home. Which of the following instructions should the nurse include?

• A. Take medication at bedtime.
• B. Check blood pressure once a week.
• C. Use a blood pressure cuff that fits snugly around the arm.
• D. Stop taking medication once blood pressure is within the normal range.

Correct answer: C

Rationale: The correct answer is C: 'Use a blood pressure cuff that fits snugly around the arm.' Using a properly fitting cuff is essential for accurate blood pressure measurements. Choice A is incorrect because the timing of medication administration should be individualized and not specified in the question. Choice B is incorrect as checking blood pressure once a week may not provide sufficient monitoring for a client with hypertension. Choice D is incorrect because stopping medication abruptly once blood pressure is normal can lead to rebound hypertension and complications.

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