Nursing Elites

1. A client is scheduled for a sigmoidoscopy and expresses anxiety about the procedure. What should the nurse do first?

• A. Offer information about the procedure steps
• B. Administer an anxiolytic before the procedure
• C. Encourage the client to discuss their fears
• D. Reassure the client that the procedure is common and safe

Correct answer: C

Rationale: The correct first action for the nurse when a client expresses anxiety about a procedure is to encourage the client to discuss their fears. By allowing the client to express their concerns, the nurse can provide personalized support, address specific worries, and offer tailored information. This approach helps to establish trust, reduce anxiety, and promote a therapeutic nurse-client relationship. Offering information about the procedure steps (Choice A) may be helpful but should come after addressing the client's fears. Administering an anxiolytic (Choice B) should not be the first action as it focuses on symptom management rather than addressing the underlying cause of anxiety. Reassuring the client that the procedure is common and safe (Choice D) is important but should follow active listening and addressing the client's fears.

2. The nurse is caring for a client with a tracheostomy who is on mechanical ventilation. What is the priority nursing intervention?

• A. Suction the tracheostomy as needed
• B. Ensure the tracheostomy ties are secure
• C. Provide humidified oxygen
• D. Clean any exudate around the tracheostomy site

Correct answer: A

Rationale: The priority nursing intervention for a client with a tracheostomy on mechanical ventilation is to suction the tracheostomy as needed. Suctioning is essential to maintain a clear airway and prevent respiratory distress. While ensuring tracheostomy ties are secure (choice B) is important, it is not as urgent as airway maintenance. Providing humidified oxygen (choice C) is beneficial but does not address the immediate need for airway clearance. Cleaning exudate around the tracheostomy site (choice D) is important for hygiene but takes precedence over ensuring airway patency through suctioning.

3. The nurse observes a client with new-onset tachycardia. What should the nurse do first?

• A. Check for the client's temperature
• B. Administer prescribed beta-blockers
• C. Assess for any chest pain or discomfort
• D. Monitor the client's blood pressure

Correct answer: C

Rationale: When a client presents with new-onset tachycardia, the first action the nurse should take is to assess for any associated symptoms like chest pain or discomfort. This is important to differentiate the potential causes of tachycardia and guide appropriate interventions. Checking the client's temperature (Choice A) may be relevant in certain situations but is not the priority when tachycardia is observed. Administering prescribed beta-blockers (Choice B) should only be done after a comprehensive assessment and healthcare provider's orders. Monitoring the client's blood pressure (Choice D) is important, but assessing for chest pain or discomfort takes precedence in this scenario to rule out cardiac causes of tachycardia.

4. A client is scheduled for an abdominal ultrasound in the morning and has been instructed to fast overnight. The client asks the nurse why fasting is necessary. What is the best response?

• A. It helps reduce the production of intestinal gases.
• B. It ensures clearer imaging by emptying the stomach.
• C. It prevents the risk of aspiration during the procedure.
• D. It is a standard procedure for all surgical interventions.

Correct answer: B

Rationale: The correct answer is B: 'It ensures clearer imaging by emptying the stomach.' Fasting before an abdominal ultrasound is essential to empty the stomach, allowing for better visualization of the abdominal organs. This improves the quality of the imaging and enhances diagnostic accuracy. Choices A, C, and D are incorrect because reducing intestinal gases, preventing aspiration, and being a standard procedure for surgical interventions are not the primary reasons for fasting before an abdominal ultrasound.

5. A client with a diagnosis of pneumonia is experiencing difficulty expectorating thick secretions. What intervention should the nurse implement to assist the client?

• A. Administer antibiotics as prescribed.
• B. Encourage increased fluid intake.
• C. Perform chest physiotherapy.
• D. Provide humidified oxygen.

Correct answer: B

Rationale: Encouraging increased fluid intake is the appropriate intervention to assist the client with pneumonia who is having difficulty expectorating thick secretions. Adequate hydration helps to thin the secretions, making them easier to cough up. Administering antibiotics (Choice A) is important for treating the infection itself but does not directly address the thick secretions. Chest physiotherapy (Choice C) may be beneficial in some cases but is not the initial intervention for thick secretions. Providing humidified oxygen (Choice D) can help with oxygenation but does not directly address the problem of thick secretions.

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