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. What information is most important for the nurse to provide to an adolescent female prescribed azithromycin for lower lobe pneumonia and recurrent chlamydia?

• A. Ensure the partner is screened for chlamydia
• B. Report any signs of liver dysfunction immediately
• C. Avoid consuming grapefruit juice while on this medication
• D. Use two forms of contraception while taking this drug

Correct answer: D

Rationale: The most important information for the nurse to provide to an adolescent female prescribed azithromycin for lower lobe pneumonia and recurrent chlamydia is to use two forms of contraception while taking this drug. Azithromycin can reduce the effectiveness of hormonal contraceptives, increasing the risk of pregnancy. It is crucial to convey this information to prevent unintended pregnancies. Option A is incorrect as the partner should be screened for chlamydia, not HIV, in this case. Option B is not the most important information to provide as liver dysfunction is a rare side effect of azithromycin. Option C is irrelevant as grapefruit juice does not interact with azithromycin. Therefore, the priority information to convey is the importance of using dual contraception to prevent pregnancy.

3. The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized elderly client with an indwelling urinary catheter every two hours. What additional action should the nurse instruct the UAP to take each time the client is turned?

• A. Empty the urinary drainage bag
• B. Feed the client a snack
• C. Offer the client oral fluids
• D. Assess the breath sounds

Correct answer: A

Rationale: The correct additional action the nurse should instruct the UAP to take each time the immobilized elderly client with an indwelling urinary catheter is turned is to empty the urinary drainage bag. This action helps to prevent backflow of urine, reduces the risk of infection, and prevents bladder distention, which are crucial for the client's comfort and health. Choices B, C, and D are incorrect as they are not directly related to the care of a client with an indwelling urinary catheter. Feeding a snack, offering oral fluids, or assessing breath sounds are important aspects of care but not the immediate action needed when turning a client with an indwelling urinary catheter to prevent complications.

4. The client enters the room of a client with Parkinson’s disease who is taking carbidopa-levodopa. The client is arising slowly from the chair while the unlicensed assistive personnel (UAP) stands next to the chair. What action should the nurse take?

• A. Demonstrate how to help the client move more efficiently
• B. Offer a PRN analgesic to reduce painful movement
• C. Affirm that the client should arise slowly from the chair
• D. Tell the UAP to assist the client in moving more quickly

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to demonstrate how to help the client move more efficiently. As the client is arising slowly from the chair, providing guidance on proper movement techniques can improve the client's mobility and safety. Offering a PRN analgesic (Choice B) is not relevant to the client's situation as there is no indication of pain. Affirming that the client should arise slowly (Choice C) does not address the need for assistance in improving movement efficiency. Instructing the UAP to assist the client in moving more quickly (Choice D) may compromise the client's safety and is not the appropriate action to take.

5. What actions should the nurse take regarding an older adult male who had an abdominal cholecystectomy and has become increasingly confused and disoriented over the past 24 hours, found wandering into another client’s room and returned to his own room by the unlicensed assistive personnel (UAP)? (Select all that apply)

• A. Apply soft upper limb restraints and raise all four bed rails
• B. Report mental status change to the healthcare provider
• C. Assess the client’s breath sounds and oxygen saturation
• D. Assign the UAP to re-assess the client’s risk for falls

Correct answer: B

Rationale: In this situation, the appropriate action for the nurse to take is to report the mental status change to the healthcare provider. Confusion and disorientation post-surgery can be indicative of various factors, such as electrolyte imbalances or respiratory issues, necessitating comprehensive assessment by the healthcare team. Applying restraints and raising bed rails may not address the underlying cause of the confusion, and assigning the UAP to reassess the client's risk for falls does not directly address the cognitive changes observed.

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