Nursing Elites

1. A patient has been diagnosed with osteoporosis and lactose intolerance. What intervention will the nurse implement?

• A. Encourage dairy alternatives.
• B. Monitor intake of vitamin D.
• C. Increase intake of caffeinated drinks.
• D. Assist the patient with daily activities.

Correct answer: B

Rationale: The correct intervention for a patient diagnosed with osteoporosis and lactose intolerance is to monitor their intake of vitamin D. Since the patient has lactose intolerance, encouraging dairy alternatives (Choice A) would not be appropriate. Increasing intake of caffeinated drinks (Choice C) is not beneficial for managing osteoporosis and may even have negative effects on bone health. Assisting the patient with daily activities (Choice D) is a general nursing intervention that may not directly address the specific needs related to osteoporosis and lactose intolerance.

2. A nurse is preparing to perform an admission assessment for a client who reports abdominal pain. Which of the following actions should the nurse take?

• A. Perform deep palpation at the end of the admission assessment
• B. Auscultate the client’s abdomen before palpation
• C. Begin palpation of the abdomen at the site of pain
• D. Assess the client’s bowel sounds using the bell of the stethoscope

Correct answer: B

Rationale: Auscultating the abdomen before palpation is the correct action for the nurse to take in this scenario. This approach helps to assess bowel sounds accurately and prevents the alteration of bowel sounds that can occur due to palpation. By auscultating first, the nurse can gather important information about bowel function before proceeding with the palpation. Choice A is incorrect because deep palpation should be avoided initially, especially in a client reporting abdominal pain, as it may cause discomfort or potential harm. Choice C is incorrect as palpation should typically start away from the site of pain to prevent exacerbating discomfort. Choice D is incorrect because assessing bowel sounds with the bell of the stethoscope is not the initial step recommended when a client reports abdominal pain; auscultation should be performed with the diaphragm of the stethoscope first.

3. A client reports mild back pain after receiving analgesia 1 hour ago. Which non-pharmacological pain method should the nurse plan to use?

• A. Apply an ice pack to the client's back for 1 hour.
• B. Remove distractions from the client’s room.
• C. Instruct the client to take deep rhythmic breaths.
• D. Encourage the client to apply a heating pad for 2 hours at a time.

Correct answer: C

Rationale: In this scenario, the nurse should instruct the client to take deep rhythmic breaths as a non-pharmacological pain management method. Deep breathing can help the client relax, reduce stress, and manage pain effectively. Applying heat or ice for prolonged periods can lead to tissue damage. Removing distractions can be helpful for promoting relaxation but may not directly address the pain itself.

4. The nurse manager hears a healthcare provider loudly criticize one of the staff nurses within the hearing of others. The employee does not respond to the healthcare provider's complaints. The nurse manager's next action should be to

• A. Approach the healthcare provider and staff nurse for a private meeting to address the situation.
• B. Allow the staff nurse to handle this situation without interference.
• C. Notify other administrative personnel of a breach of professional conduct.
• D. Request an immediate private meeting with the healthcare provider and staff nurse.

Correct answer: D

Rationale: The correct action for the nurse manager in this situation is to request an immediate private meeting with the healthcare provider and staff nurse. By doing so, the nurse manager can facilitate a more appropriate and professional discussion of the issues at hand in a private setting. Option A, which involves addressing the behavior quietly, may not effectively resolve the issue as it needs to be openly discussed. Option B is not advisable as the nurse manager should intervene to address the situation and provide support. Option C, notifying other administrative personnel, may escalate the situation unnecessarily before attempting to resolve it directly with the involved parties.

5. When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first?

• A. Loosen the right wrist restraint.
• B. Apply a pulse oximeter to the right hand.
• C. Compare hand color bilaterally.
• D. Palpate the right radial pulse.

Correct answer: A

Rationale: The correct action to take first when observing blue fingers in a client with wrist restraints is to loosen the right wrist restraint. Blue fingers indicate compromised circulation, and loosening the restraint can help restore blood flow to the area. Applying a pulse oximeter (Choice B) or palpating the right radial pulse (Choice D) may be necessary following the loosening of the restraint to assess the client's oxygen saturation and pulse. Comparing hand color bilaterally (Choice C) is important but not the immediate action needed when a circulation issue is noted in one hand.

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