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 caring for a client who is receiving chemotherapy. The client's platelet count is 25,000/mm3. Which of the following actions should the nurse take?

• A. Administer aspirin for discomfort
• B. Check the client's temperature every 4 hr
• C. Monitor the client's urine output
• D. Check for stool in the client's colostomy bag every 2 hr

Correct answer: B

Rationale: Clients with a low platelet count are at risk of bleeding and infection. Monitoring the client's temperature every 4 hours is crucial to detect early signs of infection, as they may not be able to mount a typical immune response due to their compromised platelet count. Administering aspirin (choice A) is contraindicated in clients with low platelet counts as it can further increase the risk of bleeding. Monitoring urine output (choice C) and checking for stool in a colostomy bag (choice D) are important aspects of care but are not the priority in a client with low platelet count.

3. A nurse is caring for a client who has a chest tube following thoracic surgery. Which of the following actions should the nurse take?

• A. Clamp the chest tube when assisting the client out of bed.
• B. Empty the drainage system every 8 hours.
• C. Keep the collection device below the client's chest.
• D. Strip the chest tube every 4 hours.

Correct answer: C

Rationale: The correct action for the nurse to take is to keep the collection device below the client's chest. This positioning ensures proper drainage of fluid from the chest, preventing backflow of fluids. Clamping the chest tube when assisting the client out of bed is incorrect as it can lead to fluid accumulation and potential complications. Emptying the drainage system every 8 hours is necessary but not the priority over maintaining proper positioning. Stripping the chest tube every 4 hours is an outdated practice and can cause damage to the tissue and should be avoided.

4. A nurse is providing discharge instructions to a client who has a new prescription for warfarin. Which of the following statements indicates a need for further teaching?

• A. I will avoid leafy green vegetables while taking warfarin.
• B. I will have my INR checked regularly while taking warfarin.
• C. I will use a soft toothbrush while taking warfarin.
• D. I will take this medication at the same time each day.

Correct answer: A

Rationale: The correct answer is A. Clients taking warfarin should avoid leafy green vegetables because they are high in vitamin K, which can interfere with the effectiveness of warfarin by counteracting its anticoagulant effects. Choices B, C, and D are all correct statements related to taking warfarin. Regular INR monitoring is necessary to ensure the medication is within the therapeutic range, using a soft toothbrush reduces the risk of bleeding gums, and taking the medication at the same time daily helps maintain consistent blood levels.

5. A nurse is creating a plan of care for a newly admitted client who has obsessive-compulsive disorder. Which of the following interventions should the nurse take?

• A. Allow the client enough time to perform rituals
• B. Give the client autonomy in scheduling activities
• C. Discourage the client from exploring irrational fears
• D. Provide negative reinforcement for ritualistic behaviors

Correct answer: A

Rationale: The correct intervention for a client with obsessive-compulsive disorder is to allow the client enough time to perform rituals. This helps manage anxiety and stress in individuals with OCD. Allowing time for rituals can provide a sense of control and reduce distress. Choice B, giving the client autonomy in scheduling activities, may not address the core symptoms of OCD related to rituals and compulsions. Choice C, discouraging the client from exploring irrational fears, goes against the principles of exposure therapy, which is a common treatment for OCD. Choice D, providing negative reinforcement for ritualistic behaviors, is not recommended as it can reinforce the behavior rather than help the client manage it.

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