Nursing Elites

1. What instruction is most important for the nurse to provide a female client who has just been diagnosed with trichomoniasis?

• A. Avoid douching
• B. Treat sexual partner(s) concurrently
• C. Avoid using moist washcloths when bathing
• D. Postpone becoming pregnant until the infection is treated

Correct answer: B

Rationale: The most important instruction for a female client diagnosed with trichomoniasis is to treat sexual partner(s) concurrently. This is crucial to prevent reinfection and the spread of the infection. Choice A, avoiding douching, is generally recommended for vaginal health but is not the most critical instruction in this case. Choice C, avoiding moist washcloths when bathing, is not directly related to the transmission or treatment of trichomoniasis. Choice D, postponing pregnancy until the infection is treated, is important but treating sexual partners concurrently takes precedence to prevent reinfection.

2. A client with a history of heart failure is admitted to the hospital with worsening dyspnea. The nurse notes that the client has a productive cough with pink, frothy sputum. What action should the nurse take first?

• A. Administer oxygen
• B. Perform chest physiotherapy
• C. Elevate the head of the bed
• D. Obtain a sputum specimen

Correct answer: A

Rationale: In a client with heart failure presenting with worsening dyspnea and pink, frothy sputum (indicating pulmonary edema), the priority action for the nurse is to administer oxygen. Oxygen therapy helps improve oxygenation and alleviate dyspnea by increasing the oxygen supply to the lungs. Performing chest physiotherapy, elevating the head of the bed, or obtaining a sputum specimen are not the initial actions indicated in this situation and may delay addressing the client's immediate need for improved oxygenation.

3. A postoperative client returns to the nursing unit following a ureter lithotomy via a flank incision. Which potential nursing problem has the highest priority when planning nursing care for this client?

• A. Ineffective airway clearance
• B. Altered nutrition less than body requirements
• C. Fluid volume excess
• D. Activity intolerance

Correct answer: A

Rationale: The correct answer is 'Ineffective airway clearance.' Following a ureter lithotomy via a flank incision, the highest priority nursing problem is ensuring the client's airway remains clear. This is crucial for effective breathing and oxygenation. Altered nutrition, fluid volume excess, and activity intolerance are important to address but are of lower priority compared to maintaining a clear airway postoperatively.

4. A client newly diagnosed with gastroesophageal reflux disease (GERD) is being taught about dietary management by a nurse. Which instruction should the nurse include?

• A. Avoid drinking milk
• B. Eat three large meals a day
• C. Avoid eating spicy foods
• D. Increase fluid intake with meals

Correct answer: C

Rationale: The correct instruction for a client with GERD is to avoid eating spicy foods. Spicy foods can exacerbate GERD symptoms by irritating the esophagus and increasing stomach acid production. Avoiding spicy foods can help reduce discomfort and prevent further irritation. Choices A, B, and D are incorrect. Drinking milk is not advised for GERD as it can trigger acid production. Eating three large meals a day can put pressure on the stomach, worsening symptoms. Increasing fluid intake with meals can lead to bloating and worsen GERD symptoms by causing the stomach to expand, pushing more acid into the esophagus.

5. The nurse is assessing a client who has a new cast on the left arm. Which finding should the nurse report to the healthcare provider immediately?

• A. Client reports itching under the cast
• B. Client reports pain at the cast site
• C. Client reports swelling of the fingers
• D. Client reports warmth over the casted area

Correct answer: C

Rationale: Swelling of the fingers can indicate compromised circulation, which is a serious concern in a client with a new cast. It could suggest the development of compartment syndrome, a condition where increased pressure within the muscles can lead to impaired blood flow. This can result in tissue damage and should be addressed promptly. Itching under the cast, pain at the cast site, and warmth over the casted area are common findings after cast application and may not necessarily indicate an urgent issue requiring immediate reporting to the healthcare provider.

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