Nursing Elites

1. A male client with rheumatoid arthritis is scheduled for a procedure in the morning. The procedure cannot be completed because of early morning stiffness. Which intervention should the nurse implement?

• A. Assign a UAP to assist the client with a warm shower early in the morning.
• B. Provide the client with a warm blanket to reduce stiffness.
• C. Delay the procedure until the client is less stiff.
• D. Encourage the client to perform range-of-motion exercises.

Correct answer: A

Rationale: A warm shower can help reduce morning stiffness, making the procedure more comfortable for the client. This intervention promotes comfort and mobility, addressing the immediate issue of stiffness. Providing a warm blanket (choice B) may offer some comfort but will not address the stiffness as effectively as a warm shower. Delaying the procedure (choice C) may inconvenience the client and not address the underlying stiffness issue. Encouraging range-of-motion exercises (choice D) is important for long-term management but may not provide immediate relief from the stiffness that is hindering the procedure.

2. A client presents at the clinic with blepharitis. What instructions should the nurse provide for home care?

• A. Use bilateral eye patches while sleeping to prevent injury to the eyes.
• B. Wear sunglasses when outdoors to prevent photophobia.
• C. Apply cold compresses to reduce inflammation.
• D. Apply warm moist compresses then gently scrub eyelids with diluted baby shampoo.

Correct answer: D

Rationale: The correct answer is D. Blepharitis is managed with warm moist compresses to help loosen debris and oils on the eyelids, followed by gentle scrubbing with a mild solution like diluted baby shampoo. This helps in controlling the condition. Choice A is incorrect as using eye patches while sleeping is not a standard recommendation for blepharitis. Choice B is incorrect as wearing sunglasses does not directly treat blepharitis but may help with light sensitivity. Choice C is incorrect as cold compresses are not typically used for blepharitis, as warm compresses are more effective in managing the condition.

3. The nurse is caring for a client with a chest tube following a pneumothorax. Which finding requires immediate intervention?

• A. Oxygen saturation of 94%
• B. Crepitus around the insertion site
• C. Subcutaneous emphysema
• D. Drainage of 50 ml per hour

Correct answer: C

Rationale: Subcutaneous emphysema is the most critical finding requiring immediate intervention in a client with a chest tube following a pneumothorax. It may indicate a pneumothorax recurrence or air leak, which can lead to respiratory compromise. Oxygen saturation of 94% is slightly low but may not require immediate intervention. Crepitus around the insertion site can be a normal finding post-procedure. Drainage of 50 ml per hour is within the expected range for a chest tube output and does not indicate an immediate concern.

4. A client with a history of hypertension is prescribed a beta-blocker. Which client statement indicates that further teaching is needed?

• A. ‘I will take my medication in the morning before breakfast.’
• B. ‘I should avoid eating foods high in potassium.’
• C. ‘I should change positions slowly to avoid dizziness.’
• D. ‘I should avoid abrupt discontinuation of the medication.’

Correct answer: B

Rationale: The correct answer is B: ‘I should avoid eating foods high in potassium.’ This statement indicates a misunderstanding as beta-blockers do not typically affect potassium levels. The other choices (A, C, and D) are all appropriate statements for a client prescribed a beta-blocker. Choice A shows understanding of the timing of medication administration, choice C addresses orthostatic hypotension concerns, and choice D highlights the importance of not abruptly stopping the medication to prevent adverse effects.

5. The nurse provides feeding tube instructions to the wife of a client with end-stage cancer. The client's wife performs a return demonstration correctly but begins crying and tells the nurse, 'I just don't think I can do this every day.' The nurse should direct further teaching strategies toward which learning domain?

• A. Cognitive.
• B. Affective.
• C. Comprehension.
• D. Psychomotor.

Correct answer: B

Rationale: The correct answer is B: Affective. The affective domain involves feelings and emotions, which are significant factors in the wife’s ability to cope and perform the required care. In this scenario, the wife's emotional response indicates a need for further support and teaching strategies to address her emotional concerns and build her confidence. Choices A, C, and D are incorrect because the issue at hand is not purely cognitive (knowledge), comprehension (understanding), or psychomotor (physical skills), but rather an emotional response that falls under the affective domain.

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