Nursing Elites

1. In the Emergency Department, a female client discloses that she was raped last night. Which question is most important for the nurse to ask?

• A. Does she know the person who raped her?
• B. Has she taken a bath since the rape occurred?
• C. Is the place where she lives a safe place?
• D. Did she report the rape to the police department?

Correct answer: A

Rationale: The most important question for the nurse to ask in this situation is whether the client knows the person who raped her. This question is crucial for assessing additional safety concerns, providing appropriate support, and determining the need for forensic evidence collection. Choices B, C, and D are not as critical in the immediate assessment and response to a rape victim. Asking about bathing, the safety of her home, or reporting to the police may be important but are secondary to identifying the perpetrator for safety and legal reasons.

2. A male client with hypercholesterolemia wants to change his diet to help reduce his cholesterol levels. Which breakfast items should the nurse encourage the client to eat? (Select all that apply)

• A. Sausage patties and eggs
• B. Whole wheat toast and jam
• C. Bagels and cream cheese
• D. Blackberries and oatmeal

Correct answer: B

Rationale: The correct choices are whole wheat toast and jam (B) and blackberries and oatmeal (D). Whole wheat toast and blackberries are high in fiber, which can help lower cholesterol levels. Sausage patties and eggs (A) are high in saturated fats that can raise cholesterol levels. Bagels and cream cheese (C) are not as beneficial for cholesterol control compared to high-fiber options like whole wheat toast and blackberries.

3. A 17-year-old adolescent is brought to the emergency department by both parents because the adolescent has been coughing and running a fever with flu-like symptoms for the past 24 hours. Which intervention should the nurse implement first?

• A. Obtain a chest X-ray per protocol.
• B. Place a mask on the client’s face.
• C. Assess the client’s temperature.
• D. Determine the client’s blood pressure

Correct answer: B

Rationale: The correct intervention for the nurse to implement first is to place a mask on the client's face. This is crucial to prevent the potential spread of infectious agents to others in the emergency department, considering the presenting symptoms of coughing and fever. Placing a mask helps in containing respiratory secretions and reducing the risk of airborne transmission. Assessing the client’s temperature or blood pressure can be done after ensuring infection control measures. Obtaining a chest X-ray would be a secondary intervention once immediate infection control is addressed.

4. 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.

5. A client prescribed warfarin is being taught about dietary modifications by a nurse. Which statement by the client indicates understanding of the teaching?

• A. ''I need to avoid foods high in vitamin C.''
• B. ''I should eat a consistent amount of vitamin K each day.''
• C. ''I can eat as many leafy greens as I want.''
• D. ''I should not worry about any changes in my diet.''

Correct answer: B

Rationale: The correct answer is B. Consistency in vitamin K intake is crucial for clients on warfarin to maintain stable anticoagulation levels. Option A is incorrect as vitamin C does not directly interact with warfarin. Option C is incorrect because although leafy greens are high in vitamin K, excessive consumption can affect warfarin's effectiveness. Option D is incorrect as any changes in diet, particularly in vitamin K intake, can impact the efficacy of warfarin.

Similar Questions