Nursing Elites

1. A client with a history of depression is experiencing a situational crisis. Which of the following actions should the nurse take first?

• A. Confirm the client's perception of the event.
• B. Notify the client's support system.
• C. Help the client identify personal strengths.
• D. Teach the client relaxation techniques.

Correct answer: A

Rationale: The correct answer is to confirm the client's perception of the event. In crisis intervention, understanding the client's perspective is crucial as it helps the nurse assess the situation accurately and provide tailored support. This step can also help build rapport and trust with the client. Option B, notifying the client's support system, may be important but should come after assessing the client's perception. Option C, helping the client identify personal strengths, and option D, teaching relaxation techniques, are valuable interventions but should follow the initial step of confirming the client's perception.

2. A client with a new diagnosis of celiac disease is receiving teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?

• A. I can still have oatmeal for breakfast.
• B. I need to avoid foods that contain gluten.
• C. I can have rye toast with my eggs.
• D. I can continue to eat foods made from barley.

Correct answer: B

Rationale: The correct answer is B because clients with celiac disease should avoid gluten, which is found in foods like rye and barley. Choice A is incorrect because oatmeal may contain gluten unless specified gluten-free. Choice C is incorrect as rye contains gluten. Choice D is incorrect as barley contains gluten.

3. What is the most important nursing action for a patient post-surgery?

• A. Monitor vital signs
• B. Monitor the surgical site
• C. Check blood pressure
• D. Check oxygen saturation

Correct answer: A

Rationale: The most crucial nursing action for a patient post-surgery is to monitor vital signs. Monitoring vital signs helps in detecting early signs of complications such as hemorrhage, shock, or infection. While monitoring the surgical site is important for assessing wound healing and signs of infection, it is secondary to monitoring vital signs. Checking blood pressure and oxygen saturation are also important, but they are components of monitoring vital signs.

4. What is the best position for a patient in respiratory distress?

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

Correct answer: A

Rationale: The best position for a patient in respiratory distress is the Semi-Fowler's position. This position promotes lung expansion and eases breathing by allowing the chest to expand more fully. The Trendelenburg position (choice B) where the patient's feet are higher than the head is not recommended in respiratory distress as it may cause increased pressure on the chest and reduced lung expansion. The prone position (choice C) lying on the stomach is also not optimal for respiratory distress as it can further compromise breathing. The supine position (choice D) lying flat on the back is not ideal as it may impair breathing by restricting chest expansion.

5. A nurse is providing teaching to a client who has a new prescription for levothyroxine. Which of the following instructions should the nurse include?

• A. Take this medication on an empty stomach.
• B. Take this medication at bedtime.
• C. Take this medication with food.
• D. Take this medication with a calcium supplement.

Correct answer: A

Rationale: The correct answer is A: 'Take this medication on an empty stomach.' Levothyroxine should be taken on an empty stomach to enhance absorption. Taking it with food or at bedtime can interfere with its absorption. Calcium supplements should also be avoided when taking levothyroxine as they can reduce its absorption.

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