Nursing Elites

1. When assessing a client's neurologic system, what should the nurse ask the client to close their eyes and identify?

• A. A word whispered by the nurse 30cm from the ear
• B. A number traced on the palm of the hand
• C. The vibration of a tuning fork placed on the foot
• D. A familiar object placed in the hand

Correct answer: B

Rationale: When a nurse asks a client to identify a number traced on the palm of the hand with their eyes closed, it assesses the client's ability to perceive touch sensations. This test specifically evaluates the tactile discrimination of the client. The other options do not test the client's ability to identify sensations accurately with eyes closed. Option A tests auditory perception, option C tests vibratory sense, and option D tests object recognition but not tactile discrimination, making them incorrect choices.

2. An older adult client has been hospitalized on bed rest for 1 week. The client reports elbow pain. Which of the following is an appropriate initial action for the nurse caring for this client to take?

• A. Examine the elbow
• B. Administer pain medication
• C. Apply a warm compress to the elbow
• D. Assess the client’s range of motion

Correct answer: A

Rationale: The appropriate initial action for the nurse is to examine the elbow. This step is crucial to assess the site of pain, identify any visible signs of injury or inflammation, and determine the cause of the discomfort. Administering pain medication (Choice B) should come after a thorough assessment. Applying a warm compress (Choice C) might provide temporary relief but does not address the underlying cause. Assessing the client’s range of motion (Choice D) is important but would come after the initial examination to further evaluate the elbow joint.

3. A female UAP is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP requests a change in assignment as she has not yet been fitted for a particulate filter mask. Which action should the nurse take?

• A. Advise the UAP to wear a standard face mask to take vital signs, and then get fitted for a filter mask before providing personal care
• B. Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client
• C. Instruct the UAP that a standard mask is sufficient for the provision of care for the assigned client
• D. Before changing assignments, determine which staff members have fitted particulate filter masks

Correct answer: D

Rationale: The correct course of action for the nurse is to determine which staff members have already been fitted for particulate filter masks before changing assignments. This ensures safety and compliance with infection control protocols. Option A is incorrect as wearing a standard face mask before being fitted for a filter mask does not address compliance with droplet precautions. Option B is incorrect because the priority is to ensure all staff members have appropriate equipment before providing care. Option C is incorrect as a standard mask may not offer sufficient protection when dealing with clients under droplet precautions.

4. A nurse at a long-term facility is providing a change-of-shift report to an oncoming nurse about an older adult client who has shingles. Which of the following information should the nurse include in the report?

• A. Where the client ate his breakfast
• B. The times for routine vital sign measurements
• C. The exact times the client had visitors
• D. The type of transmission-based precautions in place

Correct answer: D

Rationale: Information about transmission-based precautions is essential for infection control and continuity of care.

5. A client is receiving discharge teaching about a new prescription for digoxin (Lanoxin). Which statement by the client indicates a need for further teaching?

• A. I should avoid foods high in potassium while taking this medication.
• B. I will check my pulse before taking the medication.
• C. I should avoid taking antacids simultaneously with this medication.
• D. I will take the medication at the same time every day.

Correct answer: A

Rationale: The correct answer is A because clients taking digoxin should avoid foods high in potassium. High potassium levels can potentiate the effects of digoxin, leading to toxicity. Choices B, C, and D are correct statements regarding digoxin administration. Checking the pulse before taking the medication helps monitor for signs of digoxin toxicity. Avoiding taking antacids simultaneously prevents interactions that may reduce digoxin absorption. Taking the medication at the same time every day helps maintain a consistent blood level, ensuring optimal therapeutic effects.

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