Nursing Elites

1. A nurse on an acute med-surgical unit is performing assessments on a group of clients. Which is the highest priority?

• A. Client with surgical hypoparathyroidism and positive Trousseau's sign
• B. Client with Clostridium difficile and acute diarrhea
• C. Client with acute kidney injury and low urine specific gravity
• D. Client with oral cancer and reports a sore on his gums

Correct answer: A

Rationale: The correct answer is A. A positive Trousseau's sign indicates hypocalcemia, which can lead to life-threatening complications like tetany or laryngospasm, making it the highest priority. Choices B, C, and D, while important, do not pose immediate life-threatening risks compared to the potential complications of severe hypocalcemia seen in a client with surgical hypoparathyroidism and a positive Trousseau's sign.

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 educating a patient about their new prescription for a statin medication. What should the nurse advise the patient to avoid while taking this medication?

• A. Drinking grapefruit juice
• B. Consuming high-protein meals
• C. Exercising regularly
• D. Taking the medication in the morning

Correct answer: A

Rationale: The correct answer is A: Drinking grapefruit juice. Grapefruit juice can increase the risk of statin toxicity by interfering with the enzyme that metabolizes statin medications, leading to higher drug levels in the body. This interaction can potentially cause adverse effects. Therefore, patients should be advised to avoid consuming grapefruit juice while taking statins. Choices B, C, and D are incorrect. Consuming high-protein meals, exercising regularly, and taking the medication in the morning are not contraindicated while on statin therapy. In fact, following a healthy diet, engaging in physical activity, and taking the medication at a consistent time each day can be beneficial for patients prescribed statins.

4. A healthcare provider is caring for a patient and realizes they administered the wrong medication. What action should the healthcare provider take first?

• A. Notify the provider.
• B. Report the incident to the risk manager.
• C. Check the condition of the patient.
• D. Complete an incident report.

Correct answer: C

Rationale: The healthcare provider should first assess the patient to determine if any harm has occurred as a result of the medication error. Checking the patient's condition takes precedence as it allows for immediate intervention if necessary. Notifying the provider (choice A) can come later once the patient's condition is assessed. Reporting to the risk manager (choice B) and completing an incident report (choice D) are important steps but should follow the initial assessment of the patient to ensure timely and appropriate actions are taken.

5. A nurse is teaching a client about the dietary management of irritable bowel syndrome (IBS). Which of the following instructions should the nurse include?

• A. Decrease fiber intake
• B. Drink peppermint tea
• C. Increase foods that are high in fat
• D. Avoid foods with gluten

Correct answer: B

Rationale: The correct answer is B: 'Drink peppermint tea.' Peppermint tea can help relax the smooth muscles of the gastrointestinal tract, reducing symptoms of IBS, such as bloating and abdominal discomfort. Choices A, C, and D are incorrect. Decreasing fiber intake is not recommended for IBS management as fiber can help regulate bowel movements. Increasing foods high in fat can exacerbate symptoms of IBS, as high-fat foods can be harder to digest. Avoiding foods with gluten is more relevant for individuals with gluten sensitivity or celiac disease, not specifically for IBS management.

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