Nursing Elites

1. When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain?

• A. Daily weight
• B. Vital signs
• C. Level of consciousness
• D. Bowel sounds

Correct answer: A

Rationale: Corrected Rationale: Daily weight is the most important assessment to monitor fluid balance in clients with nephrotic syndrome. In nephrotic syndrome, excessive protein loss leads to fluid retention and edema. Monitoring daily weight allows the nurse to assess fluid status accurately. Vital signs, while important, may not directly reflect fluid balance changes in nephrotic syndrome. Level of consciousness and bowel sounds are not typically the primary assessments for monitoring fluid balance in clients with nephrotic syndrome.

2. The healthcare provider writes several prescriptions for a client diagnosed with hospital-acquired pneumonia (HAP) that include a combination of broad-spectrum antibiotics. Which intervention should the nurse implement first?

• A. Administer the first dose of antibiotics.
• B. Obtain a chest X-ray.
• C. Administer oxygen therapy.
• D. Collect blood specimens for culture prior to starting antibiotic therapy.

Correct answer: D

Rationale: Collecting blood specimens for culture prior to starting antibiotic therapy is the priority intervention in a client diagnosed with hospital-acquired pneumonia. This step is crucial to identify the causative organism responsible for the infection and ensure that the antibiotics prescribed are appropriate for effective treatment. Administering antibiotics before collecting cultures may interfere with the accuracy of culture results, potentially leading to inappropriate treatment. While administering the first dose of antibiotics is important, obtaining a chest X-ray and administering oxygen therapy are secondary interventions compared to identifying the causative organism through blood cultures.

3. When assessing an adolescent with depression, what is the most important question for the nurse to ask?

• A. What is causing your feelings of depression?
• B. Have you ever thought about suicide?
• C. What actions can we take to improve your mood?
• D. Would you like your friends to come over?

Correct answer: B

Rationale: The correct answer is B: 'Have you ever thought about suicide?' When assessing an adolescent with depression, it is crucial to ask direct questions about suicidal thoughts. This helps determine the severity of the situation, especially if the person has considered or planned to harm themselves. Choice A is not as direct and specific to suicidal ideation. Choice C focuses on improving mood rather than assessing the risk of harm. Choice D is unrelated to assessing suicidal ideation and the severity of the depression.

4. When speaking to young parents, the nurse states that lead poisoning is one of the most common preventable health problems affecting children. What condition occurs when the level of lead ingested exceeds the amount that can be absorbed by the bone?

• A. Malnutrition
• B. Anemia
• C. Bone pain
• D. Diarrhea

Correct answer: B

Rationale: The correct answer is B: Anemia. When the amount of lead ingested exceeds the amount that can be absorbed by the bone, it leads to anemia. Malnutrition (Choice A) is a state of inadequate nutrition, not directly related to lead poisoning. Bone pain (Choice C) is a symptom of lead poisoning due to its effects on bones but not directly related to lead ingestion exceeding absorption. Diarrhea (Choice D) is not a direct consequence of lead ingestion exceeding absorption by bones.

5. Which instruction should be included in the discharge teaching plan for a client who has had a cataract extraction today?

• A. Use a metal eye shield on the operative eye during the day.
• B. Administer eye ointment after applying eye drops.
• C. Light housekeeping is safe to do, but avoid heavy lifting.
• D. Refrain from sexual activities until follow-up appointment.

Correct answer: C

Rationale: The correct instruction to include in the discharge teaching plan for a client who has had a cataract extraction is that light housekeeping is safe to do, but heavy lifting should be avoided to prevent increased intraocular pressure. Choice A is incorrect as the eye shield is usually worn at night to protect the eye. Choice B is incorrect as eye ointment is usually applied after eye drops to avoid washing away the ointment. Choice D is incorrect as sexual activities should be avoided until the follow-up appointment to prevent complications.

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