Nursing Elites

1. A client with HIV and neutropenia requires specific care from the nurse. Which of the following precautions should the nurse take while caring for this client?

• A. Wear an N95 respirator while caring for the client.
• B. Use a dedicated stethoscope for the client.
• C. Insert an indwelling urinary catheter to monitor urinary output.
• D. Monitor the client’s vital signs every 8 hours.

Correct answer: B

Rationale: Using dedicated equipment for a neutropenic client, such as a stethoscope, helps prevent infections. Neutropenic clients have a weakened immune system, making them vulnerable to infections from common pathogens. Wearing an N95 respirator is not necessary unless airborne precautions are required. Inserting a urinary catheter should be avoided unless necessary to prevent introducing pathogens. Monitoring vital signs should be done more frequently, typically every 4 hours, to promptly identify any changes in the client's condition.

2. A nurse receives a report on four clients. Which client should the nurse assess first?

• A. A client scheduled for chemotherapy with a hemoglobin of 9 g/dL
• B. A client 24 hours post-TURP with small blood clots in the catheter
• C. A client receiving a blood transfusion who reports low back pain
• D. A client with a new colostomy and a reddish-pink stoma

Correct answer: C

Rationale: The correct answer is C. Low back pain during a blood transfusion is a classic sign of a transfusion reaction, specifically a transfusion-associated circulatory overload (TACO) or hemolytic reaction, both of which require immediate attention to prevent serious complications. Assessing this client first is crucial to ensure prompt intervention. Choices A, B, and D do not indicate immediate life-threatening complications and can be addressed after the client experiencing low back pain during a blood transfusion is stabilized.

3. A client is being taught about the use of levothyroxine. Which of the following should be included?

• A. It should be taken on an empty stomach
• B. Monitor for signs of hyperthyroidism
• C. It is a pain reliever
• D. It should be taken in the morning

Correct answer: B

Rationale: When educating a client about levothyroxine, it is important to emphasize the need to monitor for signs of hyperthyroidism. Levothyroxine should be taken on an empty stomach, preferably in the morning, to maximize its absorption. Choice A is incorrect as it should not be taken with food. Choice C is incorrect as levothyroxine is not a pain reliever. Choice D is incorrect as levothyroxine is usually taken in the morning.

4. A nurse is assessing a client who reports chest pain. Which of the following findings should cause the nurse to suspect a myocardial infarction?

• A. Pain improves with rest
• B. Pain radiates to the left arm.
• C. Pain worsens with deep breathing.
• D. Pain is relieved by antacids.

Correct answer: B

Rationale: The correct answer is B. Radiating pain, especially to the left arm, is a classic sign of myocardial infarction. Pain that radiates to the left arm indicates cardiac involvement, making it a significant finding. Choices A, C, and D are incorrect because chest pain that improves with rest, worsens with deep breathing, or is relieved by antacids is less likely to be associated with a myocardial infarction.

5. A nurse in an emergency department completes an assessment on an adolescent client with conduct disorder. The client threatened suicide to a teacher at school. Which of the following statements should the nurse include in the assessment?

• A. Tell me about your siblings
• B. Tell me what kind of music you like
• C. Tell me how often you drink alcohol
• D. Tell me about your school schedule

Correct answer: C

Rationale: The correct answer is C: 'Tell me how often you drink alcohol.' Alcohol use can exacerbate aggressive behaviors and is relevant for the assessment of suicide risk in adolescents with conduct disorders. Choices A, B, and D are unrelated to the assessment of suicide risk in this scenario and do not provide information that directly impacts the client's risk assessment.

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