Nursing Elites

1. A client has undergone a bronchoscopy, and a nurse is providing care post-procedure. What should the nurse do first?

• A. Monitor the client's oxygen levels
• B. Encourage the client to eat
• C. Check for a gag reflex
• D. Administer IV fluids

Correct answer: C

Rationale: After a bronchoscopy, the nurse's priority is to check for a gag reflex. This action helps assess the client's ability to protect their airway after sedation. Maintaining airway patency is crucial post-procedure. Monitoring oxygen levels is important but ensuring airway protection takes precedence. Encouraging the client to eat and administering IV fluids are essential aspects of care but are not the immediate priority in this situation.

2. A nurse in a long-term care facility is assisting with an in-service for newly hired assistive personnel about legal issues within the facility. Which of the following should the nurse include as an example of assault?

• A. Threatening to withhold food from a client
• B. Informing a client about an upcoming procedure
• C. Informing a client about risks of refusing treatment
• D. Informing a client that they will be given an injection against their will

Correct answer: D

Rationale: The correct answer is D because assault involves threatening a client with harm or unwanted procedures. In this scenario, informing a client that they will be given an injection against their will constitutes assault. Choices A, B, and C do not involve the element of threatening harm or unwanted procedures, making them incorrect. Choice A is more related to neglect, choice B is related to informing the client about a procedure, and choice C is related to informed consent and refusal of treatment, not assault.

3. What are the key signs of increased intracranial pressure (ICP) that a nurse should monitor for?

• A. Monitor for changes in level of consciousness
• B. Check for pupil dilation
• C. Assess for bradycardia
• D. Monitor for vomiting

Correct answer: A

Rationale: The correct answer is A: 'Monitor for changes in the level of consciousness.' Key signs of increased intracranial pressure (ICP) include changes in the level of consciousness and pupil dilation. Assessing for bradycardia and monitoring for vomiting are not typically considered primary signs of increased ICP. While bradycardia and vomiting can occur with increased ICP, they are not as specific or sensitive as changes in consciousness and pupil dilation.

4. A client with heart failure is on a fluid restriction. What should the nurse include in the discharge teaching?

• A. Encourage the client to drink more water to stay hydrated
• B. Monitor the client's weight daily
• C. Avoid drinking water after 6 PM
• D. Monitor fluid intake only during meals

Correct answer: B

Rationale: The correct answer is B: 'Monitor the client's weight daily.' In clients with heart failure on fluid restriction, monitoring daily weight is crucial to track fluid balance. This allows healthcare providers to assess if the client is retaining excess fluid, a common issue in heart failure. Choices A, C, and D are incorrect. Encouraging the client to drink more water contradicts the fluid restriction; avoiding drinking water after 6 PM is not specific to managing fluid restriction; and monitoring fluid intake only during meals does not provide a comprehensive assessment of fluid balance throughout the day.

5. A patient is being educated about a clear liquid diet. Which of the following should the nurse instruct the patient to avoid?

• A. Lemon-lime sports drinks
• B. Ginger ale
• C. Black coffee
• D. Orange sherbet

Correct answer: D

Rationale: The correct answer is D: Orange sherbet. A clear liquid diet consists of liquids that are transparent and easily digestible. Orange sherbet, being a frozen dessert, is not a clear liquid and should be avoided. Choices A, B, and C are all acceptable in a clear liquid diet. Lemon-lime sports drinks, ginger ale, and black coffee are clear liquids that can be included in the diet as they are transparent and leave little residue in the gastrointestinal tract, unlike orange sherbet.

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