Nursing Elites

1. Which entry in the client record best reflects significant data on a male client who is admitted with complaints of chest pain?

• A. Nurse will check client q1h for the presence of chest pain
• B. Client has a nervous, tense personality and is likely to overreact
• C. Client states he will notify the nurse if chest pain returns
• D. Client understands how to use the call button and the telephone

Correct answer: C

Rationale: The correct answer is C because documenting the client's statement about notifying the nurse if chest pain returns provides direct, relevant information about their condition. This entry indicates the client's awareness of their symptoms and their willingness to seek assistance, which is crucial in managing chest pain. Choice A is incorrect because it focuses on the nurse's actions rather than the client's condition. Choice B is irrelevant as it discusses the client's personality rather than their current health issue. Choice D, though related to communication, does not directly address the client's chest pain complaint.

2. The nurse receives change of shift report on a group of clients for the upcoming shift. A client with which condition requires the most immediate attention by the nurse?

• A. Gunshot wound three hours ago with dark drainage of 2 cm on the dressing
• B. Mastectomy 2 days ago with 50 ml bloody drainage in the Jackson-Pratt drain
• C. Collapsed lung after a fall 8 hours ago with 100 ml blood in the chest tube collection container
• D. Abdominal-perineal resection 2 days ago with no drainage on dressing and fever and chills

Correct answer: C

Rationale: A collapsed lung with significant blood accumulation requires immediate attention to prevent respiratory compromise. Option A may also require attention, but the immediate threat to airway and breathing in option C takes precedence over the others. Option B has expected drainage after a mastectomy, and option D's fever and chills, while concerning, do not pose an immediate life-threatening risk as in option C.

3. The nurse administers an oral antiviral to a client with shingles. Which finding is most important for the nurse to report to the healthcare provider?

• A. Decreased white blood cell count
• B. Pruritus and muscle aches
• C. Elevated liver function tests
• D. Vomiting and diarrhea

Correct answer: C

Rationale: The correct answer is C: Elevated liver function tests. When administering antivirals, especially orally, monitoring liver function tests is crucial as it may indicate liver toxicity. This finding should be reported promptly to the healthcare provider to prevent further complications. Choice A, decreased white blood cell count, may be expected with certain antivirals but is not the most critical finding in this scenario. Pruritus and muscle aches (choice B) are common side effects of antivirals and do not require immediate reporting. Vomiting and diarrhea (choice D) are also common side effects that may not be as concerning as elevated liver function tests.

4. The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. What action should the nurse implement immediately?

• A. Change the dressing using a compression bandage
• B. Test fluid on the dressing for glucose
• C. Document the findings in the electronic medical record
• D. Mark drainage area with a pen and continue to monitor

Correct answer: B

Rationale: The correct action for the nurse to implement immediately upon identifying clear fluid on the surgical dressing post-lumbar surgery is to test the fluid for glucose. Clear fluid could indicate cerebrospinal fluid (CSF) leakage, and testing for glucose can help confirm this. Changing the dressing using a compression bandage (Choice A) without further assessment could lead to complications. Documenting the findings (Choice C) is important but not as immediate as confirming the presence of CSF. Marking the drainage area with a pen and monitoring (Choice D) does not address the need for immediate confirmation of CSF leakage.

5. A 20-year-old female client tells the nurse that her menstrual periods occur about every 28 days, and her breasts are quite tender when her menstrual flow is heavy. She also states that she performs her breast self-examination (BSE) on the first day of every month. What action should the nurse implement in response to the client’s statements?

• A. Remind the client that it is also important to schedule an annual mammogram.
• B. Refer the client to a nurse practitioner for an in-depth review of the BSE procedure.
• C. Encourage the client to perform BSE 2 to 3 days after her menstrual period ends.
• D. Instruct the client to continue with her regular monthly exams as she is doing.

Correct answer: C

Rationale: The correct answer is to encourage the client to perform BSE 2 to 3 days after her menstrual period ends. This timing is recommended because breasts are least tender and swollen at this point, making it easier to detect any abnormalities. Choice A is incorrect because while scheduling an annual mammogram is important, it is not the immediate action needed based on the client's statements. Choice B is incorrect as the client's BSE technique timing needs adjustment rather than an in-depth review by a nurse practitioner. Choice D is incorrect because the client should modify the timing of the BSE for better effectiveness.

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