Nursing Elites

1. The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective?

• A. If I exercise at least two times weekly for one hour, I will lower my cholesterol.
• B. I need to avoid eating proteins, including red meat.
• C. I will limit my intake of beef to 4 ounces per week.
• D. My blood level of low density lipoproteins needs to increase.

Correct answer: C

Rationale: Limiting saturated fat from animal food sources to no more than 4 ounces per week is an important diet modification for lowering cholesterol. To be effective in reducing cholesterol, the client should exercise 30 minutes per day, or at least 4 to 6 times per week. Red meat and all proteins do not need to be eliminated to lower cholesterol, but should be restricted to lean cuts of red meat and smaller portions. The low density lipoproteins need to decrease rather than increase.

2. The healthcare professional retrieves hydromorphone 4mg/mL from the Pyxis MedStation, an automated dispensing system, for a client who is receiving hydromorphone 3 mg IM 6 hours PRN for severe pain. How many mL should the healthcare professional administer to the client? (Enter the numerical value only. If rounding is required, round to the nearest tenth)

• A. 0.8 mL
• B. 0.75 mL
• C. 0.7 mL
• D. 0.9 mL

Correct answer: A

Rationale: To calculate the mL to administer, divide the ordered dose (3 mg) by the concentration (4 mg/mL). 3 mg ÷ 4 mg/mL = 0.75 mL. Rounding to the nearest tenth, the correct dose to administer is 0.8 mL.

3. During a routine assessment, an obese 50-year-old female client expresses concern about her sexual relationship with her husband. Which is the best response by the nurse?

• A. Reassure the client that many obese individuals have concerns about sex.
• B. Remind the client that sexual relationships can be maintained regardless of weight.
• C. Determine the frequency of sexual intercourse.
• D. Ask the client to talk about specific concerns.

Correct answer: D

Rationale: The best response for the nurse is to ask the client to talk about specific concerns. This approach provides an opportunity for the client to express her worries openly, allowing the nurse to gather more detailed information for a comprehensive assessment and to address the client's concerns effectively.

4. The healthcare provider receives a report that a client with an indwelling urinary catheter has an output of 150 mL for the previous 6-hour shift. Which intervention should the healthcare provider implement first?

• A. Check the drainage tubing for a kink
• B. Review the intake and output record
• C. Notify the healthcare provider
• D. Give the client 8 oz of water to drink

Correct answer: A

Rationale: The first intervention should be to check the drainage tubing for a kink. This step is crucial as any kinks in the tubing could obstruct urine flow, leading to a decreased output. By ensuring the tubing is free from any obstructions, the healthcare provider can address a potential mechanical issue causing the low output before considering other interventions. Reviewing the intake and output record may provide valuable information but should come after ensuring the tubing is clear. Notifying the healthcare provider can be done later if needed, but the immediate concern is to check for any obstructions. Giving the client water to drink may be necessary depending on the assessment findings, but addressing a possible kink in the tubing takes precedence.

5. When faced with caring for a close friend in a professional setting, which action should the staff member take first?

• A. Notify the friend that all medical information will be kept confidential.
• B. Explain the relationship to the charge nurse and ask for reassignment.
• C. Approach the client and ask if the assignment is uncomfortable.
• D. Accept the assignment but protect the client's confidentiality.

Correct answer: B

Rationale: When faced with caring for a close friend in a professional setting, the staff member should first explain the relationship to the charge nurse and ask for reassignment. This is important to maintain professional boundaries, prevent conflicts of interest, and ensure that the care provided is unbiased and without compromising the friend's confidentiality. Choice A is incorrect because the priority should be on professional boundaries rather than informing the friend about confidentiality. Choice C is not appropriate as it puts the burden on the client to address any discomfort. Choice D is incorrect as accepting the assignment without addressing the potential conflict of interest could lead to compromised care.

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