Nursing Elites

1. A 30-year-old male client reports difficulty sleeping due to anxiety about his upcoming surgery. What intervention would be most appropriate for the nurse to suggest?

• A. Suggest taking a mild sedative before bed.
• B. Encourage physical activity before bedtime.
• C. Advise listening to calming music before bed.
• D. Recommend reading a book before bed.

Correct answer: A

Rationale: The most appropriate intervention for the nurse to suggest to a 30-year-old male client experiencing difficulty sleeping due to anxiety about his upcoming surgery is to recommend taking a mild sedative before bed. A mild sedative can help manage anxiety and improve sleep in such situations. Encouraging physical activity before bedtime, advising to listen to calming music, or recommending reading a book may not directly address the client's anxiety and may not be as effective in promoting sleep in this scenario.

2. A client tells the nurse, 'I have something very important to tell you if you promise not to tell.' The best response by the nurse is

• A. I must document and report any information.
• B. I can't make such a promise.
• C. That depends on what you tell me.
• D. I must report everything to the treatment team.

Correct answer: B

Rationale: The correct answer is B because the nurse cannot promise confidentiality in this context. It is essential to prioritize the safety and well-being of the client and others. Certain information, such as harm to oneself or others, must be reported to ensure appropriate interventions are taken. Choice A is incorrect because while documentation is important, confidentiality cannot be guaranteed in this situation. Choice C is incorrect as the nurse should not make promises that may conflict with their professional responsibilities. Choice D is incorrect as reporting everything to the treatment team without discretion may breach client confidentiality.

3. A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is?

• A. Difference in the intake and output
• B. Changes in the mucous membranes
• C. Skin turgor
• D. Weekly weight

Correct answer: D

Rationale: In clients with altered renal function being treated at home, weekly weight is the most accurate indicator of fluid balance. Fluid retention or loss can significantly affect weight, making it a reliable measure. Choices A, B, and C are not as accurate indicators of fluid balance as weekly weight. Intake and output differences can vary in accuracy and may not capture all aspects of fluid balance. Changes in mucous membranes and skin turgor can be influenced by factors other than fluid balance, making them less precise indicators.

4. A client with a chest tube following a pneumothorax is complaining of increased shortness of breath. What is the nurse's first action?

• A. Check for kinks in the chest tube tubing.
• B. Assess the client's lung sounds.
• C. Elevate the head of the bed to 30 degrees.
• D. Prepare for chest tube replacement.

Correct answer: C

Rationale: The correct first action for a client with a chest tube experiencing increased shortness of breath is to elevate the head of the bed to 30 degrees. This position promotes lung expansion, improves oxygenation, and can help relieve shortness of breath. Checking for kinks in the chest tube tubing would be important but not the first action in this situation. Assessing the client's lung sounds is also important but not the initial priority. Preparing for chest tube replacement is not indicated based solely on the client's complaint of increased shortness of breath.

5. A client receiving continuous ambulatory peritoneal dialysis (CAPD) has lost weight and exhibits increasing edema. What should the nurse prioritize?

• A. Evaluate the patency of the arteriovenous (AV) graft.
• B. Instruct the client to continue a fluid-restricted diet.
• C. Recommend support stockings for venous return.
• D. Monitor the client's serum albumin levels.

Correct answer: A

Rationale: In a client receiving continuous ambulatory peritoneal dialysis (CAPD) who has lost weight and exhibits increasing edema, the nurse should prioritize evaluating the patency of the arteriovenous (AV) graft. This assessment is crucial to determine if hemodialysis can be resumed, addressing the client's presenting issues effectively. Instructing the client to continue a fluid-restricted diet (choice B) may not address the underlying issue related to the CAPD. Recommending support stockings for venous return (choice C) is not directly relevant to the situation described. Monitoring the client's serum albumin levels (choice D) may be important but does not directly address the immediate concern of weight loss and increasing edema in a CAPD client.

Similar Questions