Nursing Elites

1. During a manic episode, what is the most appropriate intervention to implement first for a client with bipolar disorder?

• A. Engage the client in a quiet activity
• B. Provide a structured environment with minimal stimulation
• C. Monitor the client continuously
• D. Adjust the lighting and noise levels

Correct answer: B

Rationale: During a manic episode, individuals with bipolar disorder may experience sensory overload and agitation. Providing a structured environment with minimal stimulation is the most appropriate initial intervention as it can help reduce overwhelming sensory input and promote a sense of calm. Engaging the client in a quiet activity (Choice A) may not be effective if the environment is still overstimulating. Continuous monitoring (Choice C) is important but may not be the first intervention needed. Adjusting lighting and noise levels (Choice D) can be helpful but may not address the core issue of sensory overload and agitation during a manic episode.

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 caring for a client with an indwelling urinary catheter. What is the most important action to prevent catheter-associated urinary tract infections (CAUTI)?

• A. Perform hand hygiene before and after handling the catheter
• B. Change the catheter every 72 hours
• C. Apply antibiotic ointment at the insertion site
• D. Irrigate the catheter daily

Correct answer: A

Rationale: Performing hand hygiene before and after handling the catheter is crucial in preventing catheter-associated urinary tract infections (CAUTI). This practice helps minimize the risk of introducing harmful microorganisms into the urinary tract. Changing the catheter every 72 hours is not recommended unless clinically indicated as it can increase the risk of infection. Applying antibiotic ointment at the insertion site is not a standard practice and may contribute to antibiotic resistance. Irrigating the catheter daily is unnecessary and can introduce pathogens into the urinary tract, increasing the risk of infection.

4. A client with asthma is prescribed an albuterol inhaler. Which instruction should the nurse provide?

• A. Use the inhaler only during an asthma attack
• B. Rinse your mouth after using the inhaler
• C. Shake the inhaler before each use
• D. Exhale fully before inhaling the medication

Correct answer: C

Rationale: The correct instruction for the nurse to provide is to shake the inhaler before each use. Shaking the inhaler ensures proper mixing of the medication before administration, which is crucial for its effectiveness. Choice A is incorrect because albuterol inhalers are often used as a preventive measure, not just during asthma attacks. Choice B is a good practice to prevent oral fungal infections associated with inhaled corticosteroids, not typically with albuterol. Choice D is important for proper inhaler technique, but the primary step before inhaling is shaking the inhaler to ensure the medication is well mixed.

5. The client is 4 hours post-operative from a cesarean section and complains of gas pain and bloating. What non-pharmacological intervention can the nurse provide?

• A. Encourage the client to ambulate
• B. Apply a heating pad
• C. Provide a carbonated beverage
• D. Teach relaxation techniques

Correct answer: A

Rationale: The correct answer is to encourage the client to ambulate. Early ambulation helps alleviate gas pain and bloating by promoting gastrointestinal motility and reducing the accumulation of gas in the abdomen. Applying a heating pad may provide comfort for some types of pain but is not specifically effective for gas pain. Providing a carbonated beverage can actually worsen gas pain due to the introduction of more gas into the digestive system. Teaching relaxation techniques may be beneficial for overall comfort but may not directly address the gas pain and bloating experienced post-cesarean section.

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