Nursing Elites

1. A nurse enters a client's room to administer a medication that has been prescribed by the health care provider. The client asks the nurse about the medication. Which response by the nurse is appropriate?

• A. 'I know that it's for fluid buildup, and I think you've taken it before.''
• B. 'It's called furosemide (Lasix), and it will promote urination and rid your body of the excess fluid. It can cause an alteration in electrolyte levels, so we'll need to increase the potassium in your diet.''
• C. 'It's to help get rid of the swelling in your feet.''
• D. ''You need to discuss this medication with your health care provider.''

Correct answer: B

Rationale: A client has the right to be informed of the medication name, purpose, action, and potential undesirable effects of a prescribed medication. The nurse should provide adequate information to the client. Choice B is the correct answer as it includes the medication name, its purpose (promoting urination and eliminating excess fluid), and a potential side effect (alteration in electrolyte levels) with a plan for managing it (increasing potassium in the diet). This response demonstrates thorough and complete information. Choice A provides some information but lacks details on potential side effects and dietary adjustments. Choice C is vague and does not provide specific details about the medication. Choice D deflects the client's question and does not fulfill the client's right to information.

2. What spinal change occurring with pregnancy alters mobility?

• A. Scoliosis.
• B. Kyphosis.
• C. Lordosis.
• D. Ankylosing spondylitis.

Correct answer: C

Rationale: The correct answer is 'Lordosis.' During pregnancy, the enlarging uterus places increased weight on the spine, causing an exaggerated inward curvature known as lordosis. This change alters mobility by shifting the center of gravity forward, leading to a compensatory change in posture. Scoliosis (choice A) is a sideways curvature of the spine, not typically associated with pregnancy. Kyphosis (choice B) is an exaggerated outward curvature of the spine, while ankylosing spondylitis (choice D) is a chronic inflammatory condition affecting the spine, neither of which are directly related to the spinal changes seen in pregnancy.

3. A nurse planning care for her assigned clients understands that which aspect is the purpose of the hospital's standards of care?

• A. Identify methods of treatment.
• B. Provide direction for care based on the client's diagnosis.
• C. Identify new care methods based on current medical research.
• D. Provide direction for the practice of nursing

Correct answer: D

Rationale: The purpose of the hospital's standards of care is to provide a broad direction for the overall practice of nursing that applies to all nursing situations, across specialty areas, and across the country. These standards guide the practice of nursing by outlining the expected level of care and professional performance. While identifying methods of treatment is important, it is usually specific to individual client needs and not the overarching goal of standards of care. Providing direction for care solely based on the client's diagnosis is limited to a particular patient's treatment plan and does not encompass the broader scope of nursing practice. Identifying new care methods based on current medical research is essential for advancing healthcare practices but is not the primary purpose of the hospital's standards of care.

4. The nurse is teaching a teenage female about preventing the transmission of genital herpes. Which of the following statements should the nurse include?

• A. "Do not sit on toilet seats without protection."?
• B. "Oral sex can transmit the virus."?
• C. "This infection can be transmitted via intercourse even when you do not feel ill."?
• D. "Try to drink lots of fluids after sex to flush the reproductive tract."?

Correct answer: C

Rationale: Genital herpes can be transmitted through oral, genital, and anal sex. It's crucial to understand that the infection can be spread through intercourse even when symptoms are not present. Option A is incorrect because genital herpes is not transmitted through toilet seats. Option B is correct as oral sex can transmit the virus. Option D is incorrect as drinking fluids after sex does not prevent the transmission of genital herpes.

5. Which of the following statements indicates that the provider understands how to promote rest and sleep for the client?

• A. If you would prefer not to be disturbed, we can postpone all vital signs and assessments until tomorrow morning.
• B. With your physical therapy appointments, you cannot nap more during the day even if your sleep is often interrupted at nighttime.
• C. I can try to incorporate any sleep rituals or an ideal bedtime into your routine.
• D. We cannot group together medications, assessments, and other interventions so you may have multiple interruptions at night.

Correct answer: C

Rationale: The correct answer is, 'I can try to incorporate any sleep rituals or an ideal bedtime into your routine.' To promote rest and sleep, the provider should consider incorporating the client's preferred sleep rituals or bedtime routine. This statement shows an understanding of the importance of individualizing care to promote restful sleep. Choices A, B, and D do not directly address promoting rest and sleep. Choice A focuses on postponing assessments, Choice B addresses napping during the day, and Choice D mentions multiple interruptions at night, none of which directly support promoting rest and sleep for the client.

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