Nursing Elites

1. An 85-year-old client complains of generalized muscle aches and pains. What should be the nurse's first action?

• A. Assess the severity and location of the pain
• B. Obtain an order for an analgesic
• C. Reassure the client that this is not unusual for his age
• D. Encourage the client to increase activity

Correct answer: A

Rationale: The correct answer is to assess the severity and location of the pain. This is crucial because understanding the nature of the pain will guide the nurse in developing an appropriate pain management plan. Choice B is incorrect because administering analgesics should come after assessing the pain to ensure the right medication is given. Choice C is incorrect because dismissing the pain as a normal part of aging without proper assessment could overlook underlying issues. Choice D is incorrect as increasing activity without understanding the cause of pain may exacerbate the client's condition.

2. A nurse is assisting with the development of an education program for a community group about intake of vitamins and minerals in the diet. Which of the following foods should the nurse recommend as the best source of vitamin C?

• A. ½ cup green pepper
• B. 1 medium orange
• C. ½ cup cabbage
• D. 1 medium tomato

Correct answer: B

Rationale: The correct answer is B: 1 medium orange. Oranges are well-known for being rich in vitamin C, an essential nutrient for immune function and skin health. While choices A, C, and D also contain some vitamin C, the medium orange provides a higher amount of this vitamin compared to a ½ cup of green pepper, ½ cup of cabbage, or a medium tomato.

3. When assessing a client for signs and symptoms of a fluid volume deficit, the nurse would be most concerned with which finding?

• A. Blood pressure of 90/60 mm Hg
• B. Heart rate of 110 beats per minute
• C. Respiratory rate of 24 breaths per minute
• D. Urine output of 30 mL per hour

Correct answer: A

Rationale: Corrected Rationale: A low blood pressure of 90/60 mm Hg is a significant finding indicating fluid volume deficit. In fluid volume deficit, the body tries to compensate by increasing heart rate (choice B) to maintain cardiac output. Respiratory rate (choice C) may increase as a compensatory mechanism, but it is not the primary concern in fluid volume deficit. Urine output (choice D) may decrease in response to fluid volume deficit, but it is a late sign and not the most concerning finding.

4. A nurse is reviewing a client's admission laboratory findings that indicate the client has hyponatremia. Which of the following laboratory findings should the nurse expect to be below the expected reference range?

• A. Magnesium
• B. Calcium
• C. Chloride
• D. Potassium

Correct answer: C

Rationale: The correct answer is C: Chloride. Chloride levels are typically low in cases of hyponatremia, as it often accompanies sodium loss. Magnesium (choice A) is not directly related to hyponatremia. Calcium (choice B) and Potassium (choice D) levels are usually not significantly affected by hyponatremia, making them less likely to be below the expected reference range in this scenario.

5. The nurse is caring for a client post appendectomy. The client has developed a fever, and the incision site is red and swollen. Which of these assessments is a priority for the nurse to perform?

• A. Check the client's blood pressure
• B. Assess the client's pain level
• C. Inspect the incision site
• D. Monitor the client's respiratory status

Correct answer: C

Rationale: Inspecting the incision site is a priority in this situation because the redness and swelling indicate a potential infection. This assessment helps the nurse determine the extent of infection and the appropriate intervention, such as administering antibiotics or notifying the healthcare provider. Checking the client's blood pressure (Choice A) may be important but is not the priority in this scenario where signs of infection are present. Assessing the client's pain level (Choice B) is also important but addressing the infection takes precedence. Monitoring the client's respiratory status (Choice D) is essential but not the priority when dealing with a localized infection at the incision site.

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