Nursing Elites

1. A client is scheduled for a colonoscopy. Which preparation is the most important for the nurse to implement?

• A. Administer an enema before the procedure.
• B. Ensure the client is NPO after midnight.
• C. Encourage the client to drink clear liquids.
• D. Verify the client has completed the bowel preparation.

Correct answer: D

Rationale: The correct answer is to verify that the client has completed the bowel preparation. This step is crucial to ensure the colon is clear for accurate visualization during the procedure. Administering an enema before the procedure may not always be necessary and can be uncomfortable for the client. Ensuring the client is NPO after midnight is important, but verifying bowel preparation takes precedence. Encouraging the client to drink clear liquids is a part of the preparation process but not the most critical step compared to verifying completion of bowel preparation.

2. A pregnant client complains of heartburn. What instruction should the nurse provide?

• A. Eat spicy food to help digestion.
• B. Eat small meals throughout the day to avoid a full stomach.
• C. Drink carbonated beverages to ease digestion.
• D. Avoid drinking fluids after meals.

Correct answer: B

Rationale: The correct instruction for a pregnant client experiencing heartburn is to eat small meals throughout the day to avoid a full stomach. This helps prevent the stomach from becoming overly full, reducing the likelihood of heartburn during pregnancy. Choices A, C, and D are incorrect. Eating spicy food can exacerbate heartburn, carbonated beverages may trigger heartburn due to gas, and avoiding fluids after meals does not directly address the issue of heartburn.

3. The nurse identifies an electrolyte imbalance, a weight gain of 4.4 lbs in 24 hours, and an elevated central venous pressure for a client with full-thickness burns. Which intervention should the nurse implement?

• A. Administer diuretics
• B. Review urine output
• C. Auscultate for irregular heart rate
• D. Increase oral fluid intake

Correct answer: C

Rationale: An elevated CVP and sudden weight gain indicate fluid overload, which can strain the heart. Auscultating for an irregular heart rate is crucial as electrolyte imbalances and fluid shifts after burns can lead to cardiac complications. Monitoring the heart rate is a priority to detect any cardiac distress early. While reviewing urine output and administering diuretics are important interventions, they should come after ensuring the client's cardiac status is stable. Increasing oral fluid intake may exacerbate the fluid overload, making it an inappropriate intervention in this scenario.

4. A client with Alzheimer's disease is exhibiting signs of agitation and aggression. What is the nurse's priority intervention?

• A. Reassure the client and provide emotional support.
• B. Redirect the client to a quiet activity.
• C. Administer a PRN dose of lorazepam.
• D. Apply soft restraints as needed to prevent harm.

Correct answer: B

Rationale: The correct answer is to redirect the client to a quiet activity. This intervention helps reduce agitation and aggression in clients with Alzheimer's disease by providing a distraction and promoting a calming environment. Reassuring the client and providing emotional support (Choice A) can be beneficial but is not the priority in this situation. Administering a PRN dose of lorazepam (Choice C) should not be the first intervention due to the risk of adverse effects and should only be considered if other non-pharmacological interventions are ineffective. Applying restraints (Choice D) should be avoided unless absolutely necessary for the client's safety as it can lead to further distress and is not the initial priority intervention.

5. Which task could be safely delegated by the nurse to an unlicensed assistive personnel (UAP)?

• A. Accompanying a client who self-administers insulin
• B. Cleansing and dressing a small decubitus ulcer
• C. Monitoring a client's response to passive range of motion exercises
• D. Applying and caring for a client's rectal pouch

Correct answer: D

Rationale: The correct answer is D because tasks like applying and caring for a client's rectal pouch are within the UAP's scope of practice, as they do not require clinical judgment. Choices A, B, and C involve more complex assessments or interventions that require clinical judgment and should be performed by licensed nursing staff.

Similar Questions