Nursing Elites

1. A client with a history of chronic alcoholism is admitted with confusion, ataxia, and diplopia. Which nursing intervention is a priority for this client?

• A. Monitor for signs of alcohol withdrawal.
• B. Administer thiamine as prescribed.
• C. Provide a quiet environment to reduce confusion.
• D. Initiate fall precautions.

Correct answer: B

Rationale: The correct answer is to administer thiamine as prescribed. This intervention is a priority for clients with chronic alcoholism to prevent Wernicke's encephalopathy, a serious complication of thiamine deficiency. Monitoring for signs of alcohol withdrawal (choice A) is important but not the priority in this scenario. Providing a quiet environment (choice C) may be beneficial but does not address the immediate need to prevent Wernicke's encephalopathy. Initiating fall precautions (choice D) is also important but not the priority compared to administering thiamine to prevent a life-threatening condition.

2. The nurse is caring for a client with a tracheostomy who has thick, tenacious secretions. Which intervention should the nurse implement first?

• A. Encourage fluid intake to thin secretions.
• B. Administer a mucolytic agent.
• C. Increase humidity in the client's room.
• D. Perform deep suctioning as needed.

Correct answer: C

Rationale: Increasing humidity in the client's room is the first priority in managing thick, tenacious secretions in a client with a tracheostomy to facilitate airway clearance. This intervention helps to moisten secretions, making them easier to clear. Encouraging fluid intake (Choice A) can be beneficial, but increasing humidity should be addressed first. Administering a mucolytic agent (Choice B) and performing deep suctioning (Choice D) are interventions that can be considered after addressing humidity if necessary, but they are not the initial priority.

3. A client with a postoperative wound that eviscerated yesterday has an elevated temperature. What is the most important intervention for the nurse to implement?

• A. Initiate contact isolation.
• B. Obtain a wound swab for culture and sensitivity.
• C. Assess temperature every 4 hours.
• D. Use alcohol-based solutions for hand hygiene.

Correct answer: B

Rationale: Obtaining a wound swab for culture and sensitivity is the most important intervention in this situation. It helps identify the presence of infection in the postoperative wound that could be causing the elevated temperature. By obtaining a wound swab, healthcare providers can determine the appropriate treatment needed to address any infection. Initiating contact isolation (Choice A) may be necessary in certain situations but is not the priority in this case. Assessing temperature (Choice C) is important but does not directly address the underlying cause of the elevated temperature. Using alcohol-based solutions for hand hygiene (Choice D) is a standard practice for infection control but is not the most crucial intervention in this scenario.

4. A client with a history of hypertension is admitted with a blood pressure of 200/110 mmHg. Which intervention should the nurse implement first?

• A. Administer an antihypertensive medication as prescribed.
• B. Monitor the client's urine output.
• C. Administer oxygen therapy as prescribed.
• D. Obtain an arterial blood gas (ABG) sample.

Correct answer: D

Rationale: The correct answer is to obtain an arterial blood gas (ABG) sample. In a client with severe hypertension, it is essential to assess for metabolic or respiratory acidosis which can be done through an ABG sample. Administering antihypertensive medication without assessing the acid-base status of the client can lead to potential complications. Monitoring urine output and administering oxygen therapy are important interventions but are not the priority in this situation where the focus should be on assessing acidosis.

5. A female client with breast cancer who completed her first chemotherapy treatment today at an outpatient center is preparing for discharge. Which behavior indicates that the client understands her care needs?

• A. Rented movies and borrowed books to use while passing time at home
• B. Made an appointment with the oncologist for follow-up treatment
• C. Expressed concern about hair loss and fatigue
• D. Asked for dietary recommendations to manage nausea

Correct answer: A

Rationale: Choice A is the correct answer. Renting movies and borrowing books to use at home indicate that the client understands the need for rest and self-care after chemotherapy. This behavior demonstrates the client's intention to engage in activities that promote relaxation and recovery. Choices B, C, and D are incorrect because making an appointment for follow-up treatment, expressing concern about side effects like hair loss and fatigue, and asking for dietary recommendations are important but do not directly reflect the client's understanding of her immediate care needs post-chemotherapy.

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