Nursing Elites

1. A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process?

• A. Obtain client information
• B. Develop a plan of care
• C. Implement nursing interventions
• D. Evaluate the client's response to treatment

Correct answer: A

Rationale: The correct answer is A: Obtain client information. The first step in the nursing process is assessment, which involves gathering data about the client's condition, needs, and preferences. This information forms the foundation for developing a comprehensive plan of care. Developing a plan of care (Choice B) comes after assessment to address the identified needs. Implementing nursing interventions (Choice C) follows the development of the plan of care. Evaluating the client's response to treatment (Choice D) occurs after implementing the interventions to determine the effectiveness of the care provided. Therefore, the initial and priority step is to obtain client information through assessment.

2. A client who is lactating is being taught about taking medications by a nurse. Which of the following actions should the nurse recommend to minimize the entry of medication into breast milk?

• A. Drink 8 oz of water with each dose of medication.
• B. Use medications that have a short half-life.
• C. Take each dose right after breastfeeding.
• D. Pump breast milk and discard it prior to feeding the newborn.

Correct answer: C

Rationale: Taking medications immediately after breastfeeding helps minimize the amount of medication that enters breast milk. By doing so, there is a longer interval between the medication intake and the next breastfeeding session, reducing the concentration of the medication in breast milk. Options A and B are incorrect as drinking water with medication or using medications with a short half-life do not directly minimize the entry of medication into breast milk. Option D is unnecessary and wasteful as pumping and discarding breast milk before feeding is not as effective as timing medication intake with breastfeeding to reduce medication transfer into breast milk.

3. A healthcare provider is assessing a client's ability to balance. Which of the following actions is appropriate when the healthcare provider conducts a Romberg test?

• A. Ask the client to extend their arms in front of their body.
• B. Ask the client to walk in a straight line heel to toe.
• C. Have the client stand with their feet together.
• D. Have the client place their hands on their hips.

Correct answer: C

Rationale: The Romberg test is a neurological test that assesses proprioception and balance. To perform this test, the client is asked to stand with their feet together and arms at their sides while closing their eyes. By removing visual input, the test challenges the vestibular and proprioceptive systems. Choices A, B, and D are incorrect because they do not align with the proper procedure for conducting the Romberg test. Extending arms in front, walking heel to toe, or placing hands on hips are not part of the Romberg test protocol and may introduce variables that could affect the assessment of balance.

4. While changing a client's postoperative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given there is a positive MRSA, which is the most important action for the nurse to take?

• A. Force oral fluids
• B. Request a nutrition consult
• C. Initiate contact precautions
• D. Limit visitors to immediate family only

Correct answer: C

Rationale: The correct action for the nurse to take in this situation is to initiate contact precautions. MRSA (Methicillin-resistant Staphylococcus aureus) is a highly contagious bacterium that spreads through direct contact. Contact precautions involve wearing gloves and gowns to prevent the spread of infection to other patients or healthcare workers. Force-feeding oral fluids, requesting a nutrition consult, or limiting visitors to immediate family only are not the most appropriate actions in this scenario. These actions do not directly address the need to prevent the spread of MRSA, which is crucial in a healthcare setting.

5. A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching?

• A. Sit on the toilet 30 minutes after eating a meal.
• B. Increase your fluid intake to help with bowel movements.
• C. Exercise regularly to improve bowel function.
• D. Consume more high-fiber foods to prevent constipation.

Correct answer: A

Rationale: The correct statement the nurse should include in the teaching is to 'Sit on the toilet 30 minutes after eating a meal.' This advice can help establish a regular bowel routine and improve bowel movement. Option B, 'Increase your fluid intake to help with bowel movements,' while important, is not specific to the time after eating and does not directly address the need for establishing a routine. Option C, 'Exercise regularly to improve bowel function,' is also important but does not address the timing of bowel movements. Option D, 'Consume more high-fiber foods to prevent constipation,' is beneficial for preventing constipation but does not address the timing aspect related to bowel movements.

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