Nursing Elites

1. A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?

• A. Oral mucosa
• B. Conjunctivae
• C. Soles of the feet
• D. Ear lobes

Correct answer: A

Rationale: Central cyanosis is best assessed by examining the oral mucosa, as it is a more reliable indicator compared to other areas like the conjunctivae, soles of the feet, and ear lobes. The oral mucosa reflects the oxygen saturation levels of the blood more accurately. Conjunctivae and ear lobes may show cyanosis, but they are not as reliable as the oral mucosa. The soles of the feet are not typically used to assess central cyanosis.

2. A nurse provides instructions to a client about preventing injury while using crutches. What should the nurse tell the client to avoid?

• A. An abnormal stance
• B. Injury to the nerves
• C. A fall and further injury
• D. Skin breakdown

Correct answer: B

Rationale: The correct answer is B: Injury to the nerves. Resting the underside of the arm on the crutch pad can injure the nerves. Choice A, an abnormal stance, is not directly related to nerve injury while using crutches. Choice C, a fall and further injury, is a general risk associated with improper crutch use but does not specifically address nerve injury. Choice D, skin breakdown, is a concern related to pressure ulcers but not the primary focus when discussing injury prevention related to crutch use.

3. A client with leukemia is considered for a bone marrow transplant. Which principle of healthcare ethics is being practiced by minimizing harm to the client?

• A. Justice
• B. Beneficence
• C. Nonmaleficence
• D. Autonomy

Correct answer: C

Rationale: The correct answer is C: Nonmaleficence. Nonmaleficence is the ethical principle that focuses on avoiding harm to the patient. In this scenario, by considering a bone marrow transplant for the client with leukemia, healthcare professionals are practicing nonmaleficence by aiming to minimize harm. Choice A, Justice, pertains to fairness in the distribution of resources and decisions, which is not the primary focus in this situation. Choice B, Beneficence, involves promoting the patient's well-being, which is related but not directly addressing the act of minimizing harm. Choice D, Autonomy, refers to respecting the patient's right to make decisions about their own care, which is not the key principle at play when minimizing harm in this context.

4. A case manager at an assisted living facility is reviewing the use of complementary health practices by several clients. Which of the following actions should the case manager plan to take?

• A. Plan to report a client's use of echinacea to the provider as a contraindication to aspirin therapy
• B. Plan to schedule time for a new client to continue tai chi practice as a stress reduction technique
• C. Tell a client that yoga has not been proven effective to reduce manifestations of menopause
• D. Tell a client who drinks cranberry juice daily that it can help treat existing urinary tract infections

Correct answer: B

Rationale: The correct answer is B. Tai chi is a recognized complementary health practice for stress reduction. Scheduling time for a new client to continue tai chi practice aligns with supporting holistic care. Choice A is incorrect because reporting a client's use of echinacea as a contraindication to aspirin therapy is not necessary without further context or evidence of interactions. Choice C is wrong because yoga can indeed be effective in reducing manifestations of menopause. Choice D is also incorrect because while cranberry juice is known to help prevent urinary tract infections, it is not typically used to treat existing infections.

5. A nurse is providing discharge teaching for a client prescribed warfarin. What should be included in the teaching?

• A. Avoid foods rich in vitamin K
• B. Take warfarin with meals
• C. Take aspirin for pain relief
• D. Report unusual bleeding or bruising

Correct answer: D

Rationale: The correct answer is D. When a client is prescribed warfarin, they should be educated to report any unusual bleeding or bruising promptly. Choices A, B, and C are incorrect. Avoiding foods rich in vitamin K is not necessary when taking warfarin, as long as intake remains consistent. Warfarin does not need to be taken with meals, and aspirin should not be taken for pain relief due to its blood-thinning effects, which can increase the risk of bleeding when combined with warfarin.

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