Nursing Elites

1. A client with a history of adrenal insufficiency is admitted with acute adrenal crisis. The client complains of nausea and joint pain, vital signs show a temperature of 102°F, heart rate of 138, and blood pressure of 80/60. Which intervention should the nurse implement first?

• A. Obtain an analgesic prescription.
• B. Infuse an intravenous fluid bolus.
• C. Administer PRN oral antipyretic.
• D. Cover the client with a cooling blanket.

Correct answer: B

Rationale: In acute adrenal crisis, the priority intervention is to infuse an intravenous fluid bolus to address the hypotension (blood pressure of 80/60) and help stabilize the client's condition. Adequate fluid volume is crucial in managing adrenal insufficiency crisis. Options A, C, and D do not directly address the hypotension and fluid volume depletion that are critical in this situation. Analgesics, antipyretics, and cooling blankets may be considered later, but the immediate focus should be on fluid resuscitation.

2. An adolescent with intellectual disability is admitted for refusing to complete oral hygiene. A behavior modification program is recommended. Which reinforcement is best?

• A. Unit tasks for each omitted teeth brushing.
• B. Candy for each successfully completed hygiene task.
• C. Privilege restriction for refusing hygiene tasks.
• D. Preferred activities or tokens for compliance.

Correct answer: D

Rationale: The best reinforcement strategy in this scenario is providing preferred activities or tokens for compliance. Positive reinforcement is effective in behavior modification programs for individuals with intellectual disabilities. Offering preferred activities or tokens serves as a reward for completing the desired behavior, in this case, oral hygiene tasks. Choices A, B, and C do not focus on reinforcing the desired behavior with positive incentives. Choice A does not provide a positive reinforcement for compliance but rather focuses on the omission of a task. Choice B uses candy, which may not be ideal for oral hygiene. Choice C involves punishment rather than positive reinforcement.

3. The nurse instructs a client to use an incentive spirometer. The client performs a return demonstration as seen in the video. Which action should the nurse take in response to the return demonstration?

• A. Instruct the client to inhale more deeply
• B. Remind the client to cough after using the spirometer
• C. Praise the client for correct usage
• D. Suggest increasing the frequency of spirometer use

Correct answer: B

Rationale: The correct action for the nurse to take in response to the return demonstration of using an incentive spirometer is to remind the client to cough after using the device. Coughing helps clear secretions from the lungs and promotes lung expansion. Instructing the client to inhale more deeply (Choice A) is not necessary as the primary focus after using the spirometer is to clear secretions. Praising the client for correct usage (Choice C) is positive but does not address the essential step of coughing. Suggesting increasing the frequency of spirometer use (Choice D) is not the immediate action needed after the demonstration.

4. A client with schizophrenia is experiencing auditory hallucinations. What is the nurse's best response?

• A. Encourage the client to ignore the voices and stay focused on reality.
• B. Acknowledge the client's feelings and ask what the voices are saying.
• C. Redirect the conversation to help distract the client from the hallucinations.
• D. Offer reassurance that the voices cannot harm the client.

Correct answer: B

Rationale: The best response for a client with schizophrenia experiencing auditory hallucinations is to acknowledge the client's feelings and ask what the voices are saying. This approach helps build rapport with the client, demonstrates empathy, and allows the nurse to assess the content of the hallucinations. Understanding the content is crucial to determine whether the client is at risk of harm. Encouraging the client to ignore the voices (Choice A) may invalidate their experience. Redirecting the conversation (Choice C) may not address the underlying issue of the hallucinations. Offering reassurance (Choice D) without understanding the content may overlook potential risks.

5. While changing a client's chest tube dressing, the nurse notes a cracking sensation when gentle pressure is applied to the skin at the insertion site. What is the best action for the nurse to take?

• A. Apply a pressure dressing around the chest tube site.
• B. Administer an oral antihistamine.
• C. Assess for allergies to topical cleaning agents.
• D. Measure the area of swelling and crackling.

Correct answer: D

Rationale: When a nurse observes crepitus around a chest tube site, it could indicate subcutaneous emphysema, a potentially serious condition where air gets trapped under the skin. Measuring the area of swelling and crackling is important as it helps monitor the progression of subcutaneous emphysema. Applying a pressure dressing (choice A) might not address the underlying cause and could potentially worsen the condition. Administering an oral antihistamine (choice B) is not indicated for crepitus at a chest tube site. Assessing for allergies to topical cleaning agents (choice C) is important but not the immediate priority when crepitus is observed.

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