Nursing Elites

1. A client with anxiety disorder is experiencing increased anxiety prior to vaginal delivery. What should the nurse’s initial action be?

• A. Increase the client's sedative dose
• B. Encourage the client to express her feelings and provide emotional support
• C. Initiate breathing techniques to manage anxiety
• D. Administer anxiolytic medication to calm the client

Correct answer: B

Rationale: The correct initial action for a client with anxiety disorder experiencing increased anxiety prior to vaginal delivery is to encourage the client to express her feelings and provide emotional support. Emotional support is crucial in reducing anxiety during childbirth. Initiating breathing techniques or administering medications should come after emotional support has been provided. Increasing sedative doses may not address the underlying emotional needs of the client and can have potential risks.

2. A client on mechanical ventilation is experiencing high-pressure alarms. What action should the nurse implement first?

• A. Check the client's oxygen saturation.
• B. Assess the client's endotracheal tube for obstruction.
• C. Reposition the client to relieve pressure.
• D. Suction the client's airway.

Correct answer: B

Rationale: The correct answer is to assess the client's endotracheal tube for obstruction. When a client on mechanical ventilation experiences high-pressure alarms, the first action should be to check for any potential obstructions in the airway, which can trigger the alarms. Checking the oxygen saturation (Choice A) is important but not the priority when dealing with high-pressure alarms. Repositioning the client (Choice C) may be necessary later but should not be the initial action. Suctioning the client's airway (Choice D) should only be done after assessing for and addressing any obstructions in the endotracheal tube.

3. A client with psoriasis is prescribed topical corticosteroids. What side effect should the nurse monitor for?

• A. Monitor for weight gain and skin thinning.
• B. Assess for increased sensitivity to sunlight.
• C. Monitor for hair loss and excessive bruising.
• D. Report any signs of increased redness or itching.

Correct answer: D

Rationale: The correct answer is D. When a client with psoriasis is prescribed topical corticosteroids, the nurse should monitor for signs of increased redness or itching. This is because topical corticosteroids can cause skin thinning and increased redness if overused. Choices A, B, and C are incorrect because weight gain, sensitivity to sunlight, hair loss, and excessive bruising are not typically associated with the use of topical corticosteroids.

4. A male client with cirrhosis has jaundice and pruritus. He tells the nurse that he has been soaking in hot baths at night with no relief of his discomfort. Which action should the nurse take?

• A. Instruct the client to use a moisturizer immediately after the bath
• B. Advise the client to take shorter baths with less water
• C. Suggest taking antihistamines for the pruritus
• D. Encourage the client to use cooler water and apply calamine lotion after soaking

Correct answer: D

Rationale: In this situation, the client's pruritus (itching) is likely exacerbated by hot baths, which can worsen the itching sensation. Using cooler water will help soothe the skin and reduce pruritus. Additionally, applying calamine lotion after soaking can provide further relief. Instructing the client to use a moisturizer immediately after the bath (Choice A) may not address the root cause of pruritus aggravated by hot baths. Advising the client to take shorter baths with less water (Choice B) might not be as effective in relieving the itching sensation caused by cirrhosis. Suggesting antihistamines for the pruritus (Choice C) may not directly address the impact of hot baths on the client's discomfort.

5. A client with rheumatoid arthritis is prescribed disease-modifying antirheumatic drugs (DMARDs). What should the nurse monitor for?

• A. Monitor for signs of liver toxicity.
• B. Assess for gastrointestinal side effects, such as nausea or diarrhea.
• C. Monitor for signs of infection, such as fever or sore throat.
• D. Administer DMARDs with meals to prevent gastrointestinal upset.

Correct answer: C

Rationale: Correct Answer: Monitoring for signs of infection, such as fever or sore throat, is crucial when a client with rheumatoid arthritis is prescribed disease-modifying antirheumatic drugs (DMARDs). DMARDs can suppress the immune system, making individuals more susceptible to infections. Early detection of infections allows for prompt treatment and helps prevent complications. Choices A, B, and D are incorrect because while liver toxicity and gastrointestinal side effects are possible side effects of DMARDs, monitoring for signs of infection takes priority due to the increased risk of infections associated with these medications.

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