Nursing Elites

1. A client with a history of falls is under the care of a nurse. Which of the following actions should be the nurse’s priority?

• A. Complete a fall-risk assessment.
• B. Educate the client and family about fall risks.
• C. Eliminate safety hazards from the client’s environment.
• D. Ensure the client uses assistive aids in their possession.

Correct answer: C

Rationale: The nurse's priority should be to eliminate safety hazards from the client's environment as it directly reduces the risk of falls. Addressing environmental hazards is an immediate and crucial step in preventing falls. While completing a fall-risk assessment is important to understand the client's risk factors, educating the client and family about fall risks is essential for prevention, and ensuring the use of assistive aids is crucial for safety, eliminating safety hazards takes precedence as it directly mitigates the risk of falls.

2. A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as experiencing chronic pain?

• A. A client who has a broken femur and reports hip pain.
• B. A client who has incisional pain 72 hours following pacemaker insertion.
• C. A client who has food poisoning and reports abdominal cramping.
• D. A client who has episodic back pain following a fall 2 years ago.

Correct answer: D

Rationale: Chronic pain is typically defined as pain lasting longer than 3-6 months or persisting after the expected time for tissue healing. Episodic back pain following a fall 2 years ago fits the criteria for chronic pain. Option A describes acute pain related to a recent fracture. Option B describes acute postoperative pain. Option C describes acute pain associated with an acute condition (food poisoning). Therefore, the correct identification of a client experiencing chronic pain is the one with episodic back pain from a past injury, as it has lasted beyond the normal healing time.

3. A client has extracellular fluid volume deficit. Which of the following findings should the nurse expect?

• A. Postural hypotension
• B. Distended neck veins
• C. Dependent edema
• D. Bradycardia

Correct answer: A

Rationale: Postural hypotension is a common sign of extracellular fluid volume deficit due to decreased blood volume, leading to a drop in blood pressure upon standing. Distended neck veins, dependent edema, and bradycardia are not typically associated with extracellular fluid volume deficit. Distended neck veins are more indicative of fluid volume overload, dependent edema is a sign of fluid retention, and bradycardia is not a common finding in extracellular fluid volume deficit.

4. The healthcare provider is educating a client about dietary changes to prevent the recurrence of calcium oxalate kidney stones. Which food should the provider advise the client to avoid?

• A. Spinach
• B. Bananas
• C. Chicken
• D. Rice

Correct answer: A

Rationale: The correct answer is A: Spinach. Spinach is high in oxalate, a compound that can contribute to the formation of calcium oxalate kidney stones. Therefore, advising the client to avoid spinach is crucial in reducing the risk of stone recurrence. Bananas (choice B) are not high in oxalate and do not directly contribute to the formation of calcium oxalate stones, so they do not need to be avoided. Similarly, choices C and D, chicken, and rice, are not typically associated with high oxalate content, making them safe choices and do not need to be avoided specifically to prevent calcium oxalate kidney stones.

5. The healthcare provider is caring for a patient who has multiple ticks on lower legs and body. What should the healthcare provider do to rid the patient of ticks?

• A. Use blunt tweezers and pull upward with steady pressure.
• B. Burn the ticks with a match or a small lighter.
• C. Allow the ticks to drop off by themselves.
• D. Apply miconazole and cover with plastic.

Correct answer: A

Rationale: Correct answer: When removing ticks, it is essential to use blunt tweezers to grasp the tick as close to the head as possible and pull upward with even, steady pressure to remove the entire tick. Option B is incorrect because burning ticks can increase the risk of infection and is not recommended. Option C is incorrect as waiting for ticks to drop off by themselves prolongs potential exposure to tick-borne diseases. Option D is incorrect as miconazole is an antifungal medication and not used for tick removal.

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