Nursing Elites

1. A client reports feeling isolated and lonely two weeks after the death of a spouse. What is the most appropriate nursing intervention?

• A. Encourage talking about the spouse
• B. Provide information on grief counseling
• C. Suggest joining a support group
• D. All of the above

Correct answer: D

Rationale: During the grieving process, individuals may benefit from various interventions to cope with their emotions and feelings of isolation. Encouraging the client to talk about the deceased spouse can provide an outlet for their emotions. Providing information on grief counseling can offer professional support tailored to their needs. Suggesting joining a support group can help the client connect with others who are going through a similar experience, fostering a sense of belonging and understanding. By selecting 'All of the above' as the correct answer, it acknowledges the importance of utilizing multiple strategies to support the client's emotional health and facilitate the grieving process effectively. The other options alone may not address all aspects of the client's needs during this difficult time.

2. During a tonic-clonic seizure, what is the nurse's priority intervention?

• A. Insert an oral airway
• B. Administer oxygen via nasal cannula
• C. Restrain the client's arms and legs
• D. Protect the client's head from injury

Correct answer: D

Rationale: During a tonic-clonic seizure, the nurse's priority intervention is to protect the client's head from injury. This is crucial to prevent trauma, as head injuries can be severe during a seizure. Inserting an oral airway may cause injury or obstruction during the seizure and is not recommended. Administering oxygen via nasal cannula can be done after ensuring the client's safety. Restraining the client's arms and legs is also not recommended as it can lead to further injury or harm.

3. The nurse is assessing a client with cirrhosis who has developed ascites. What is the most important intervention to include in the care plan?

• A. Restrict sodium intake
• B. Encourage high-protein meals
• C. Increase fluid intake
• D. Administer diuretics as prescribed

Correct answer: D

Rationale: The correct answer is to administer diuretics as prescribed. Diuretics are often prescribed to help manage fluid accumulation in ascites, which is a common complication of cirrhosis. Restricting sodium intake (Choice A) is essential in managing ascites, but administering diuretics takes precedence in the care plan. Encouraging high-protein meals (Choice B) and increasing fluid intake (Choice C) are not the primary interventions for managing ascites in cirrhosis.

4. A client with a diagnosis of deep vein thrombosis (DVT) is receiving anticoagulant therapy. Which instruction should the nurse provide to the client?

• A. Avoid walking as much as possible
• B. Report any signs of bleeding to the healthcare provider
• C. Take aspirin for additional pain relief
• D. Wear compression stockings at night

Correct answer: B

Rationale: Reporting signs of bleeding is essential while on anticoagulant therapy to prevent complications.

5. When assisting a client to obtain a sputum specimen, the nurse observes the client cough and spit a large amount of frothy saliva in the specimen collection cup. What action should the nurse implement next?

• A. Advise the client that suctioning will be used to obtain another specimen
• B. Re-instruct the client in coughing techniques to obtain another specimen
• C. Provide the client a glass of water and mouthwash to rinse the mouth
• D. Label the container and place the container in a biohazard transport bag

Correct answer: C

Rationale: After observing the client cough and produce frothy saliva in the collection cup, the nurse should provide the client with a glass of water and mouthwash to rinse the mouth. This action helps clear the mouth of contaminants, ensuring a more accurate sputum specimen for diagnostic testing. Option A is incorrect because suctioning is not the appropriate next step in this situation. Option B is unnecessary as re-instructing the client in coughing techniques may not address the immediate issue of contaminated saliva in the specimen. Option D is premature since labeling and transporting the container should only be done after obtaining a valid specimen.

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