Nursing Elites

1. A nurse is caring for an older adult who has a nonpalpable skin lesion that is less than 0.5cm (0.2in) in diameter. Which term should the nurse use to document this finding?

• A. Papule
• B. Macule
• C. Nodule
• D. Tumor

Correct answer: B

Rationale: The correct answer is B: Macule. A macule is a flat, nonpalpable skin lesion that is smaller than 1 cm in diameter. In this case, the lesion is less than 0.5cm, fitting the description of a macule. A papule (choice A) is a solid, elevated lesion less than 0.5 cm in diameter. A nodule (choice C) is a solid, elevated lesion that is 0.5 cm or larger in diameter. A tumor (choice D) refers to a mass of abnormal tissue growth, which is not applicable in this scenario.

2. A nurse is assessing a client who reports pain and tenderness at the site of an indwelling urinary catheter. What is the nurse's first action?

• A. Irrigate the catheter with normal saline
• B. Notify the provider
• C. Assess for signs of infection
• D. Administer prescribed antibiotics

Correct answer: B

Rationale: The correct first action for the nurse to take when a client reports pain and tenderness at the site of an indwelling urinary catheter is to notify the provider. Pain and tenderness at the catheter site may indicate infection, and the healthcare provider needs to be informed for further assessment and appropriate interventions. Irrigating the catheter with normal saline (Choice A) should not be the initial action without consulting the provider first. While assessing for signs of infection (Choice C) is important, notifying the provider takes precedence. Administering prescribed antibiotics (Choice D) should only be done based on the provider's orders after assessment and confirmation of infection.

3. A nurse is caring for a client who reports a decrease in the effectiveness of their arthritis medication. What factor should the nurse identify as contributing to this decrease?

• A. Improved mobility
• B. Bowel inflammation
• C. Long-term use of the medication
• D. Frequent dehydration

Correct answer: B

Rationale: The correct answer is B: Bowel inflammation. Bowel inflammation can decrease the absorption of medications, reducing their effectiveness. Improved mobility (choice A) would generally not contribute to a decrease in medication effectiveness. Long-term use of the medication (choice C) may lead to tolerance but would not directly cause a decrease in effectiveness. Frequent dehydration (choice D) can affect overall health but is not a direct factor in the medication's effectiveness for arthritis.

4. A nurse is assessing a client who is at risk for pressure injuries. Which intervention should the nurse include in the plan of care?

• A. Reposition the client every 4 hours
• B. Use a special mattress for the client
• C. Keep the client on bedrest
• D. Encourage the client to remain in one position

Correct answer: B

Rationale: The correct answer is B: 'Use a special mattress for the client.' Using a special mattress reduces pressure on bony prominences and helps prevent pressure injuries. Repositioning the client every 4 hours (choice A) is important but using a special mattress is more effective. Keeping the client on bedrest (choice C) can increase the risk of pressure injuries due to prolonged immobility. Encouraging the client to remain in one position (choice D) is incorrect as it can lead to pressure injuries by exerting pressure on the same areas for an extended period.

5. A nurse is sitting with the partner of a client who recently died. Which action should the nurse take to facilitate mourning?

• A. Avoid discussing the deceased
• B. Encourage the partner to ask for help when needed
• C. Suggest bereavement counseling
• D. Offer to contact family members

Correct answer: B

Rationale: Encouraging the partner to ask for help when needed is the most appropriate action in this scenario as it promotes healthy coping mechanisms and support during the mourning process. This approach empowers the individual to seek assistance when required, fostering a sense of control and acknowledging the partner's autonomy in dealing with their grief. Avoiding discussing the deceased (Choice A) may hinder the grieving process by suppressing emotions and preventing the partner from expressing their feelings. While suggesting bereavement counseling (Choice C) is important, the immediate support and encouragement to seek help when needed are crucial. Offering to contact family members (Choice D) may not be the most effective step at this stage, as the focus should be on empowering the partner to cope and seek help on their terms.

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