Nursing Elites

1. During a repeat home visit to see an 84-year-old widow, the nurse discovers that the client is unkempt, smells of stale urine, and does not recognize her neighbors or the nurse. What action should the nurse take?

• A. Call the pharmacy to determine what medications she is taking
• B. Seek the family's assistance in taking care of the client
• C. Complete a physical and mental exam on the client
• D. Call the adult protective services to obtain emergency nursing home placement

Correct answer: C

Rationale: In this scenario, the nurse should prioritize completing a physical and mental exam on the client. This action is crucial to assess the client's health status comprehensively and identify any underlying issues contributing to her unkempt appearance, odor of stale urine, and confusion. Calling the pharmacy to determine medications (Choice A) may be important but is not the immediate priority. Seeking family assistance (Choice B) can be helpful, but the client's condition requires a thorough assessment first. While adult protective services (Choice D) may be necessary in the future, the immediate action should be to assess the client's physical and mental health status.

2. When documenting assessment data, which statement should the nurse record in the narrative nursing notes?

• A. Client appears anxious.
• B. Client's skin is warm and dry.
• C. S1 murmur auscultated in supine position.
• D. Client is resting quietly.

Correct answer: C

Rationale: The correct answer is C. When documenting assessment data in the narrative nursing notes, it is essential to include objective findings that are specific, clear, and descriptive. 'S1 murmur auscultated in supine position' provides a precise and objective assessment finding that can aid in accurately documenting the client's condition. Choices A, B, and D are more subjective statements that lack the specificity and clarity required for detailed documentation. 'Client appears anxious' and 'Client is resting quietly' are subjective observations, while 'Client's skin is warm and dry' is an objective finding but may not be as significant or relevant for comprehensive documentation as the auscultated murmur.

3. The healthcare professional is developing a program to educate parents on childhood safety. Which topic should be prioritized?

• A. the benefits of car seats
• B. how to childproof the home
• C. the importance of helmet use
• D. ways to prevent drowning

Correct answer: B

Rationale: Prioritizing the topic of how to childproof the home is crucial as it provides a holistic approach to safeguarding children from various injuries within the home environment. Childproofing the home addresses a wide range of hazards such as falls, burns, poisoning, and choking incidents. While topics like the benefits of car seats, the importance of helmet use, and ways to prevent drowning are important, childproofing the home covers a broader spectrum of safety measures that can significantly reduce the risk of injuries for children.

4. The healthcare provider is assessing a client who is receiving total parenteral nutrition (TPN). Which finding requires immediate intervention?

• A. Blood glucose level of 150 mg/dL.
• B. Weight gain of 2 pounds in 24 hours.
• C. Decreased urine output.
• D. Temperature of 100.3°F (37.9°C).

Correct answer: C

Rationale: Decreased urine output in a client receiving total parenteral nutrition (TPN) requires immediate intervention because it can indicate potential complications such as fluid overload or kidney dysfunction. Monitoring urine output is crucial in assessing renal function and fluid balance in patients on TPN. A blood glucose level of 150 mg/dL is within a normal range and may not require immediate intervention. Weight gain of 2 pounds in 24 hours could be a concern but may not be as urgent as addressing decreased urine output. A temperature of 100.3°F (37.9°C) is slightly elevated but may not be directly related to TPN administration unless there are other symptoms of infection present.

5. What information should the nurse provide a client who has undergone cryosurgery for stage 1A cervical cancer?

• A. Expect heavy, watery vaginal discharge for 3 to 6 weeks.
• B. Use a tampon instead of a sanitary napkin.
• C. Report any severe cramping immediately.
• D. Avoid sexual intercourse for 3 to 6 weeks.

Correct answer: D

Rationale: After cryosurgery for stage 1A cervical cancer, clients should avoid sexual intercourse for 3 to 6 weeks to reduce the risk of infection. Heavy, watery vaginal discharge is expected but not the focus of post-procedure instructions. Using tampons is contraindicated as they can introduce bacteria into the healing cervix. While reporting severe cramping is important, avoiding sexual intercourse is the priority to prevent complications.

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