Nursing Elites

1. A client with dyspnea is being admitted to the medical unit. To best prepare for the client's arrival, the nurse should ensure that the client's bed is in which position?

• A. Trendelenburg
• B. Supine
• C. Prone
• D. Fowler's

Correct answer: D

Rationale: Fowler's position (head elevated at 45-60 degrees) improves oxygenation by expanding the lungs, making it the best position for clients with dyspnea. Supine or prone positions restrict lung expansion, and Trendelenburg position (head down) can exacerbate breathing difficulties by increasing pressure on the lungs and diaphragm.

2. A client with rheumatoid arthritis is prescribed methotrexate. What is the most important teaching point for the nurse to provide?

• A. Take the medication with food to avoid gastrointestinal upset.
• B. Monitor for signs of infection, such as a sore throat.
• C. Increase fluid intake to prevent dehydration.
• D. Avoid direct sunlight to prevent photosensitivity.

Correct answer: D

Rationale: The most important teaching point for a client prescribed methotrexate is to avoid direct sunlight to prevent photosensitivity. Methotrexate can make the skin more sensitive to sunlight, increasing the risk of sunburn and skin damage. Choices A, B, and C are important aspects of client care but are not specifically related to the side effect of photosensitivity caused by methotrexate.

3. An S3 heart sound is auscultated in a client in her third trimester of pregnancy. What intervention should the nurse take?

• A. Perform a 12-lead electrocardiogram
• B. Document in the client's record
• C. Notify the healthcare provider immediately
• D. Assess for signs of heart failure

Correct answer: B

Rationale: An S3 heart sound is often a normal finding in pregnant women due to increased blood volume and cardiac output. The nurse should document the finding as part of the routine assessment unless accompanied by other abnormal symptoms. Performing a 12-lead electrocardiogram (Choice A) is unnecessary for a normal S3 heart sound in pregnancy. Notifying the healthcare provider immediately (Choice C) is premature and may lead to unnecessary interventions. Assessing for signs of heart failure (Choice D) is not indicated as an isolated S3 heart sound is typically benign in pregnancy.

4. The nurse is assessing a client 2 hours postoperatively following an appendectomy. The nurse should intervene for which abnormal finding?

• A. Heart rate of 88 beats per minute
• B. Blood pressure of 100/60
• C. Oxygen saturation of 94%
• D. Respiratory rate of 16

Correct answer: C

Rationale: The correct answer is C. Oxygen saturation levels below 95% indicate hypoxia and require immediate intervention. A heart rate of 88 beats per minute, a blood pressure of 100/60, and a respiratory rate of 16 are within normal ranges and do not require immediate intervention. Oxygen saturation is a critical parameter reflecting the client's oxygenation status.

5. 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.

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