Nursing Elites

1. While receiving a change of shift report on a group of clients, which patient should the nurse assess first?

• A. The client who has a fractured femur and reports sharp chest pain.
• B. The client who has a fever and is receiving antibiotics.
• C. The client who has a urinary tract infection and reports pain with urination.
• D. The client who is scheduled for surgery in the afternoon.

Correct answer: A

Rationale: The nurse should assess the client with a fractured femur and sharp chest pain first. Sharp chest pain in this client may indicate a pulmonary embolism, a life-threatening condition requiring immediate attention. The other options describe important patient conditions but do not pose an immediate threat to life like a potential pulmonary embolism does.

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

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

Correct answer: C

Rationale: The correct term the nurse should use to document this finding is 'Macule.' A macule is a flat, nonpalpable skin lesion that is smaller than 1 cm in diameter. In this case, the lesion described is less than 0.5 cm, making it appropriate to classify it as a macule. 'Papule' (Choice A) refers to a solid, elevated skin lesion, 'Vesicle' (Choice B) is a small fluid-filled blister, and 'Nodule' (Choice D) is a solid, elevated skin lesion that is larger and deeper than a papule, none of which accurately describe the lesion in question.

3. A nurse is teaching a group of assistive personnel (AP) about caring for clients with Alzheimer's disease. Which of the following information should the nurse include in the teaching?

• A. Explain procedures clearly to the client before initiating care
• B. Encourage a variety of activities to engage the client
• C. Use simple and calm communication with a client who has difficulty speaking
• D. Provide supervision to prevent a client from becoming injured or lost

Correct answer: D

Rationale: The correct answer is D because clients with Alzheimer's disease can be prone to wandering and getting lost. Providing supervision can help prevent injuries and ensure their safety. Choices A, B, and C are incorrect because explaining procedures clearly, encouraging varied activities, and using simple communication are important but not specifically focused on the safety aspect of preventing clients from getting lost or injured.

4. A nurse is caring for a client at 32 weeks gestation with a history of cardiac disease. Which position should the nurse recommend to promote optimal cardiac output?

• A. The chest
• B. Standing
• C. Supine
• D. Left lateral

Correct answer: D

Rationale: The left lateral position is the correct choice to promote optimal cardiac output in a pregnant client at 32 weeks gestation with cardiac disease. This position improves venous return and decreases pressure on the vena cava, helping optimize cardiac output. Standing (choice B) would not be recommended as it may decrease venous return. The supine position (choice C) should be avoided in pregnant clients with cardiac disease as it can compress the vena cava, reducing cardiac output and potentially causing hypotension. The chest (choice A) is not a valid position recommendation for optimizing cardiac output in this scenario.

5. A nurse is assessing a client for signs of deep vein thrombosis (DVT). Which of the following findings should the nurse look for?

• A. Swelling in the limb
• B. Decreased heart rate
• C. Increased appetite
• D. Improved mobility

Correct answer: A

Rationale: The correct answer is A: Swelling in the limb. Swelling, particularly in one limb, is a common sign of deep vein thrombosis (DVT) and should be assessed. This swelling is often accompanied by pain, redness, and warmth in the affected area. Choices B, C, and D are incorrect because decreased heart rate, increased appetite, and improved mobility are not typically associated with DVT. The main focus in assessing for DVT is recognizing the signs and symptoms related to venous thrombosis.

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