Nursing Elites

1. A male client presents to the clinic stating that he has a high-stress job and is having difficulty falling asleep at night. The client reports having a constant headache and is seeking medication to help him sleep. Which intervention should the nurse implement?

• A. Determine the client’s sleep and activity pattern
• B. Obtain a prescription for the client to take when stressed
• C. Refer the client for a sleep study and neurological follow-up
• D. Teach coping strategies to use when feeling stressed

Correct answer: D

Rationale: Teaching coping strategies is an appropriate first intervention for a client experiencing sleep difficulties and stress. It can help manage stress and improve sleep without immediately resorting to medication. By teaching coping strategies, the nurse empowers the client to address the underlying issues contributing to his sleep problems rather than just providing a temporary solution. Referring for a sleep study and neurological follow-up may be considered later if the client's sleep issues persist despite implementing coping strategies. Determining the client’s sleep and activity pattern may be helpful but addressing coping strategies is more beneficial in managing stress-related sleep issues. Obtaining a prescription for the client to take when stressed does not address the root cause of the sleep problem and may lead to dependency on medication rather than promoting long-term solutions.

2. During the digital removal of a fecal impaction, the nurse should stop the procedure and take corrective action if which client reaction is noted?

• A. Temperature increases from 98.8° to 99.0° F.
• B. Pulse rate decreases from 78 to 52 beats/min.
• C. Respiratory rate increases from 16 to 24 breaths/min.
• D. Blood pressure increases from 110/84 to 118/88 mmHg.

Correct answer: B

Rationale: During digital removal of a fecal impaction, a vagal response can occur due to stimulation of the anal sphincter. If the client experiences bradycardia (pulse rate decreases), the nurse should stop the procedure immediately and take corrective action to prevent any complications. Choices A, C, and D are incorrect because they do not indicate a vagal response, which is the expected adverse reaction during this procedure.

3. The UAP is positioning a newly admitted client with a seizure disorder in a supine position. The UAP is placing soft pillows along the side rails. What action should the nurse take?

• A. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows
• B. Ensure that the UAP has placed pillows effectively to protect the client
• C. Ask the UAP to use some pillows to prop the client in a side-lying position
• D. Assume responsibility for placing the pillows while the UAP completes another task

Correct answer: A

Rationale: To prevent the risk of suffocation, soft blankets are preferred over pillows for padding side rails in clients with seizure disorders. Pillows can pose a suffocation hazard, especially during a seizure episode when the client's movements may be uncontrolled. Instructing the UAP to use soft blankets instead of pillows is crucial for ensuring the client's safety. Choice B is incorrect because pillows can be hazardous during a seizure. Choice C is incorrect as side-lying position may not be appropriate for a client with a seizure disorder. Choice D is incorrect as it does not address the safety concern related to using pillows.

4. What is the most important instruction for the nurse to provide a client with a new colostomy regarding stoma care?

• A. Cleanse the stoma with hydrogen peroxide and water.
• B. Apply a moisture barrier cream to the peristomal skin.
• C. Measure the stoma using a stoma guide.
• D. Use a dry gauze pad to clean the stoma.

Correct answer: C

Rationale: Measuring the stoma using a stoma guide (C) is crucial as it ensures that the appliance fits properly, which is essential for preventing skin irritation and leakage. Proper measurement helps in selecting the right size of the appliance, promoting comfort and optimal stoma care. In contrast, cleansing with hydrogen peroxide (A), applying a moisture barrier cream (B), and using a dry gauze pad (D) are important but not as critical as ensuring the correct fit of the stoma appliance.

5. During a urethral catheterization on a female, where would the healthcare provider observe the urethral meatus after separating the labia?

• A. Between the vaginal orifice and the anus.
• B. Between the clitoris and the vaginal orifice.
• C. Just above the clitoris.
• D. Within the vaginal canal.

Correct answer: B

Rationale: The correct location of the urethral meatus in females is between the clitoris and the vaginal orifice. When performing a urethral catheterization, it is crucial to identify this anatomical landmark for correct insertion of the catheter. Choice A is incorrect as the urethral meatus is not located between the vaginal orifice and the anus. Choice C is incorrect as the urethral meatus is not located just above the clitoris. Choice D is incorrect as the urethral meatus is not within the vaginal canal.

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