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 male client reports that he took tadalafil 10 mg two hours ago and now feels flushed. What action should the nurse take?

• A. Instruct the client to increase oral fluid intake.
• B. Reassure the client that flushing is a common side effect.
• C. Advise the client to take nitroglycerin as a precaution.
• D. Ask the client to come to the emergency room.

Correct answer: B

Rationale: The correct answer is B: Reassure the client that flushing is a common side effect. Tadalafil, a medication used for erectile dysfunction, can cause flushing as a common side effect. In this situation, the nurse should provide reassurance to the client that the flushing is expected and not necessarily a cause for concern. Increasing oral fluid intake (choice A) may be beneficial for other conditions but is not directly related to tadalafil-induced flushing. Advising the client to take nitroglycerin (choice C) is incorrect, as nitroglycerin is not indicated for flushing. Asking the client to come to the emergency room (choice D) is unnecessary at this point since flushing is a known side effect and does not typically require urgent medical attention.

3. While assessing an older client's fall risk, the client reports living at home alone and never falling. Which action should the nurse take?

• A. Suggest moving to an assisted living facility
• B. Continue to obtain client data needed to complete the fall risk survey
• C. Reduce the frequency of fall risk assessments for this client
• D. Confirm that the client is safe living alone

Correct answer: B

Rationale: The correct action for the nurse to take is to continue obtaining client data to complete the fall risk survey. Even though the client reports never falling, it is essential to assess all fall risk factors comprehensively. Fall risk surveys provide valuable information on mobility, vision, medications, and other factors that can impact safety. Option A is incorrect because suggesting moving to an assisted living facility is premature without completing the fall risk assessment. Option C is incorrect as reducing the frequency of fall risk assessments could overlook potential risk factors. Option D is incorrect as the client's statement alone is not enough to confirm their safety living alone; a thorough assessment is necessary.

4. A client with a history of hypertension and hyperlipidemia is admitted with chest pain. What is the nurse's priority action?

• A. Administer prescribed nitroglycerin.
• B. Obtain a 12-lead electrocardiogram (ECG).
• C. Check the client's vital signs.
• D. Place the client on continuous telemetry.

Correct answer: B

Rationale: The correct answer is to obtain a 12-lead electrocardiogram (ECG). This action is crucial in assessing the heart's electrical activity and helps in the evaluation of chest pain. Administering nitroglycerin (Choice A) may be necessary but should come after obtaining the ECG to confirm the diagnosis. Checking vital signs (Choice C) is important but does not provide direct information about the heart's electrical status. Placing the client on continuous telemetry (Choice D) may be appropriate later but does not provide immediate information on the heart's electrical activity as an ECG does.

5. A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states 'I don't think I need those medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects.' The nurse should understand that

• A. A referral is needed to the psychiatrist who is to provide the client with answers
• B. The client has a right to know about the prescribed medications
• C. Such education is an independent decision of the individual nurse whether or not to teach clients about their medications
• D. Clients with schizophrenia are at a higher risk of psychosocial complications when they know about their medication side effects

Correct answer: B

Rationale: The correct answer is B. The client has a legal right to be informed about their treatment, including medication uses and side effects, as part of informed consent. This helps ensure that the client can make an informed decision about their care. Choice A is incorrect because the nurse can provide the client with information about their medications. Choice C is incorrect as it is not an independent decision of the nurse but a professional responsibility to educate clients. Choice D is incorrect as knowledge about medication side effects can actually empower clients to manage their condition effectively.

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