Nursing Elites

1. The nurse believes that a client who frequently requests pain medication may have a substance abuse problem. Which intervention reflects the nurse's value of client autonomy over veracity?

• A. Administer the prescribed analgesic when requested
• B. Enroll the client in a substance abuse program
• C. Collaborate with the healthcare provider to provide a placebo
• D. Document the frequency of medication requests

Correct answer: A

Rationale: Administering the prescribed analgesic when requested reflects the nurse's value of client autonomy over veracity. This choice respects the client's right to manage their pain as they see fit. Enrolling the client in a substance abuse program (Choice B) assumes substance abuse without evidence and infringes on the client's autonomy. Providing a placebo (Choice C) violates the principle of beneficence and autonomy by deceiving the client. Documenting the frequency of medication requests (Choice D) is important for assessment but does not directly address the client's autonomy in managing their pain.

2. The nurse is planning care for a client who is receiving radiation therapy for breast cancer. Which intervention is most important for the nurse to include?

• A. Encourage the client to use sunscreen
• B. Apply lotion to the radiated area
• C. Keep the area dry and clean
• D. Encourage the client to exercise the arm

Correct answer: C

Rationale: Keeping the radiated area dry and clean is crucial to prevent skin irritation and infection. Radiation therapy can cause skin changes, making it susceptible to irritation and infection. Using sunscreen (Choice A) is not usually recommended on the radiated area as it can further irritate the skin. Applying lotion (Choice B) may not be suitable as it can trap moisture and cause skin breakdown. While encouraging exercise (Choice D) is important, keeping the area dry and clean takes precedence to prevent complications during radiation therapy.

3. When preparing an educational program for adolescents about the risks of multiple sexual partners, which information is most important to include?

• A. Condoms provide reliable protection against sexually transmitted infections.
• B. Having multiple sexual partners increases the risk of contracting sexually transmitted infections.
• C. The use of oral contraceptives can reduce the risk of sexually transmitted infections.
• D. Having multiple sexual partners increases the risk of developing cancer.

Correct answer: B

Rationale: The correct answer is B because having multiple sexual partners significantly increases the risk of contracting sexually transmitted infections (STIs). This information is crucial for adolescents to understand the potential consequences of engaging in risky sexual behaviors. Choice A is incorrect because while condoms are important for protection, they are not 100% effective. Choice C is incorrect as oral contraceptives do not protect against STIs. Choice D is incorrect as the immediate concern for adolescents in this context is the risk of STIs rather than cancer.

4. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 liters per minute via nasal cannula. The client reports difficulty breathing. What action should the nurse take first?

• A. Increase the oxygen flow rate
• B. Instruct the client to breathe deeply and cough
• C. Check the client's oxygen saturation level
• D. Place the client in a high-Fowler's position

Correct answer: C

Rationale: The correct action for the nurse to take first when a client with COPD reports difficulty breathing while receiving oxygen is to check the client's oxygen saturation level. This helps in determining the adequacy of oxygenation and identifying the cause of the breathing difficulty. Increasing the oxygen flow rate (Choice A) may not be appropriate without knowing the current oxygen saturation level. Instructing the client to breathe deeply and cough (Choice B) may not address the immediate need for oxygen assessment. Placing the client in a high-Fowler's position (Choice D) can help with breathing but should come after ensuring proper oxygenation.

5. A primigravida at term comes to the prenatal clinic and tells the nurse that she is having contractions every 5 min. The nurse monitors the client for one hour, using an external fetal monitor, and determines that the client’s contractions are 7 to 15 minutes apart, lasting 20 to 30 seconds, with mild intensity by palpation. What action should the nurse take?

• A. Tell the client to go directly to the hospital for admission to labor and delivery for active labor
• B. Send the client home and instruct her to call the clinic when her contractions occur 5 minutes apart for one hour
• C. Tell the client to check into the hospital within the next hour for evaluation of possible urinary tract infection
• D. Advise the client to rest and hydrate, then return if contractions become more regular

Correct answer: B

Rationale: The client should be instructed to call when contractions are 5 minutes apart for an hour to ensure she is in active labor before going to the hospital.

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