Nursing Elites

1. A nurse has been caring for a female client who has bruises on her arms that she explains are a result of physical abuse by her husband. The client states, “I don’t know how much longer I can take this, but I’m afraid he’ll really hurt me if I leave.” Which of the following is an appropriate nursing intervention?

• A. Offer to speak to the client’s husband regarding his abusive behavior
• B. Help the client to recognize signs of escalation in abusive behavior
• C. Assist the client in identifying personal behaviors that trigger abuse
• D. Assist the client in reporting the abusive behavior to authorities

Correct answer: D

Rationale: Assisting the client in reporting the abuse is a critical step in ensuring her safety and initiating legal action to protect her from further harm. Option A is inappropriate as it may escalate the situation and put the client at further risk. Option B focuses on the client recognizing signs of abuse, which is not as urgent as reporting it to authorities. Option C places the responsibility on the client for triggering the abuse, which is victim-blaming and not helpful in this context.

2. A nurse is planning care for a group of postoperative clients. Which of the following interventions should the nurse identify as the priority?

• A. Administer IV pain medication to a client who reports pain as a 6 on a scale of 0 to 10
• B. Administer oxygen to a client who has an oxygen saturation of 91%
• C. Instruct a client who is 1 hr postoperative about coughing and deep breathing exercises
• D. Initiate an infusion of 0.9% sodium chloride for a client who has just had abdominal surgery

Correct answer: B

Rationale: When using the ABC approach to client care, the nurse should identify that the priority intervention is administering oxygen. In this scenario, the client's oxygen saturation is only 91%, which is below the normal range of 95% and above. Oxygen is essential for adequate tissue perfusion and oxygenation of vital organs. Administering oxygen takes precedence over other interventions to ensure the client's physiological needs are met first. Choice A can be addressed after ensuring adequate oxygenation. Choice C is important for preventing postoperative complications but is not as urgent as addressing oxygen saturation. Choice D is a common postoperative intervention, but in this case, ensuring adequate oxygenation is the priority over IV fluid administration.

3. A nurse is caring for an older adult who has a non-palpable skin lesion that is less than 0.5 cm in diameter. Which term should the nurse use to document this finding?

• A. Vesicle
• B. Macule
• C. Papule
• D. Nodule

Correct answer: B

Rationale: The correct answer is B: Macule. A macule is a non-palpable skin lesion smaller than 1 cm in diameter. In this case, the skin lesion described is less than 0.5 cm, making it consistent with a macule. Vesicle (choice A) is a small blister filled with clear fluid, papule (choice C) is a solid, raised skin lesion less than 0.5 cm in diameter, and nodule (choice D) is a palpable, solid lesion larger than 0.5 cm in diameter. Therefore, choices A, C, and D describe skin lesions that do not match the characteristics of the lesion presented in the question.

4. A nurse is teaching a client about the use of pantoprazole. Which of the following should be included?

• A. It should be taken on an empty stomach
• B. It reduces stomach acid production
• C. It can cause headache
• D. It should not be used with other antacids

Correct answer: C

Rationale: The correct information to include when teaching a client about pantoprazole is that it can cause headaches. Option A is incorrect because pantoprazole is usually taken before meals. Option B is not necessary information for the client to know. Option D is not directly related to the side effects of pantoprazole.

5. A nurse is providing teaching to a client who has a new prescription for lisinopril. Which of the following statements by the client indicates a need for further teaching?

• A. I will notify my doctor if I develop a cough.
• B. I will avoid using salt substitutes.
• C. I will increase my intake of potassium-rich foods.
• D. I will monitor my blood pressure regularly.

Correct answer: C

Rationale: The correct answer is C. Clients taking lisinopril should avoid potassium-rich foods because ACE inhibitors can increase potassium levels, potentially leading to hyperkalemia. Choices A, B, and D are all correct statements. Clients should notify their doctor if they develop a cough as it can indicate a potential side effect of lisinopril. Avoiding salt substitutes is important as they may contain potassium chloride, which can also raise potassium levels. Monitoring blood pressure regularly is essential when taking an antihypertensive medication like lisinopril.

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