Nursing Elites

1. A client is vomiting, and a nurse is providing care. Which of the following actions should the nurse take first?

• A. Administer an antiemetic to the client
• B. Notify housekeeping
• C. Prevent the client from aspirating
• D. Provide the client with an emesis basin

Correct answer: C

Rationale: Preventing aspiration is the priority when caring for a client who is vomiting to reduce the risk of pneumonia or other respiratory complications. Aspiration can occur when vomitus enters the airway, leading to respiratory distress. Ensuring the airway is protected during vomiting episodes is essential. Administering an antiemetic (Choice A) can be considered after addressing the immediate risk of aspiration. Notifying housekeeping (Choice B) and providing an emesis basin (Choice D) are important but are secondary to preventing aspiration, which is crucial for the client's safety and well-being.

2. A nurse is assessing the skin of an immobilized patient. What will the nurse do?

• A. Use a standardized tool such as the Braden Scale.
• B. Limit the amount of fluid intake.
• C. Have special times for inspection so as not to interrupt routine care.
• D. Assess the skin every 4 hours.

Correct answer: A

Rationale: The correct answer is A. When assessing the skin of an immobilized patient, it is essential to use a standardized tool such as the Braden Scale to identify patients at high risk for impaired skin integrity. This tool helps in early identification and appropriate intervention. Choice B, limiting fluid intake, is not directly related to skin assessment. Choice C, having special times for inspection, may not ensure timely identification of skin issues. Choice D, assessing the skin every 4 hours, lacks specificity regarding the use of a validated tool for risk assessment.

3. A nurse is providing discharge teaching to a client following a cataract extraction. Which of the following instructions should the nurse include?

• A. Bend at the waist when picking up objects.
• B. Avoid lying on the operative side.
• C. Avoid lifting more than 10 lb.
• D. Apply ice to the affected eye.

Correct answer: C

Rationale: The correct answer is C: 'Avoid lifting more than 10 lb.' After a cataract extraction, the nurse should instruct the client to avoid lifting heavy objects to prevent increased intraocular pressure, which could lead to complications. Choices A, B, and D are incorrect. A - 'Bend at the waist when picking up objects' can increase intraocular pressure; B - 'Avoid lying on the operative side' is not a specific concern related to cataract extraction; D - 'Apply ice to the affected eye' is not a standard post-cataract extraction instruction.

4. A county public health nurse is developing a list of interventions to address the three core functions of public health. Which of the following interventions should the nurse include as part of the assurance function?

• A. Use surveillance to investigate outbreaks of foodborne illness
• B. Monitor the incidence rates of varicella every 2 months
• C. Organize an immunization clinic for at-risk members of the community
• D. Educate the community about the health risks of alcohol use

Correct answer: C

Rationale: The correct answer is C: 'Organize an immunization clinic for at-risk members of the community.' This intervention is part of the assurance function in public health, as it ensures that the community has access to preventive health services. Choice A is related to the assessment function as it involves surveillance to investigate outbreaks. Choice B is also related to the assessment function since it involves monitoring incidence rates. Choice D is associated with the policy development function as it involves educating the community about health risks.

5. A healthcare provider is assessing a client who has been using beclomethasone for 2 weeks to manage her asthma. What is the priority to report to the provider?

• A. Sore throat
• B. Cough
• C. Chest tightness
• D. Bronchospasms

Correct answer: D

Rationale: The correct answer is D: Bronchospasms. Bronchospasms can indicate worsening asthma and are considered a severe side effect that requires immediate attention. While sore throat, cough, and chest tightness are also possible side effects of beclomethasone, bronchospasms are of higher concern due to their association with significant respiratory distress and potential exacerbation of asthma symptoms.

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