Nursing Elites

1. A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

• A. Insert a tongue depressor into the client's mouth.
• B. Restrain the client's arms and legs.
• C. Turn the client onto their side.
• D. Place the client in a prone position.

Correct answer: C

Rationale: During a tonic-clonic seizure, the nurse should turn the client onto their side. This action helps maintain an open airway by allowing saliva or any vomitus to drain out of the mouth, reducing the risk of aspiration. Inserting a tongue depressor (choice A) is incorrect as it can cause injury to the client's mouth and is not recommended during a seizure. Restraining the client's arms and legs (choice B) can lead to physical harm and should be avoided. Placing the client in a prone position (choice D) is dangerous as it can obstruct the airway and hinder breathing, which is not suitable for a client experiencing a seizure.

2. Which electrolyte imbalance is most concerning for a patient on loop diuretics?

• A. Hypokalemia
• B. Hyponatremia
• C. Hyperkalemia
• D. Hypercalcemia

Correct answer: A

Rationale: The correct answer is hypokalemia. Loop diuretics can cause potassium depletion leading to hypokalemia, which is particularly concerning as it can result in cardiac arrhythmias. Hyponatremia (choice B) is not typically associated with loop diuretics. Hyperkalemia (choice C) is less common in patients on loop diuretics. Hypercalcemia (choice D) is not a typical electrolyte imbalance associated with loop diuretics.

3. A nurse is planning care for a client who has chronic obstructive pulmonary disease (COPD). Which of the following interventions should the nurse include in the plan of care?

• A. Encourage the client to breathe deeply and cough every 4 hours.
• B. Provide a diet that is high in carbohydrates and low in protein.
• C. Teach the client pursed-lip breathing technique.
• D. Restrict the client's fluid intake to 1,500 mL per day.

Correct answer: C

Rationale: The correct answer is C: Teach the client pursed-lip breathing technique. Pursed-lip breathing helps clients with COPD improve oxygenation and reduce shortness of breath. Choice A is incorrect because deep breathing and coughing are not recommended every 4 hours for clients with COPD. Choice B is incorrect because a diet high in carbohydrates and low in protein is not specifically indicated for COPD. Choice D is incorrect because fluid restriction is not a standard intervention for COPD unless the client has comorbid conditions that necessitate it.

4. A nurse is performing a dressing change for a client who has a sacral wound using negative pressure wound therapy. Which of the following actions should the nurse take first?

• A. Apply skin preparation to wound edges.
• B. Don sterile gloves.
• C. Normal saline
• D. Determine pain level.

Correct answer: D

Rationale: The correct answer is to determine the pain level first. Assessing the client's pain is crucial before any procedure to ensure their comfort and safety. Applying skin preparation to wound edges (Choice A) may come later in the process after ensuring the client's comfort. Donning sterile gloves (Choice B) is important before directly handling the wound but can follow pain assessment. Normal saline (Choice C) might be used during wound cleansing but is not the initial step in this situation.

5. A nurse is providing discharge teaching to a client who has a new prescription for warfarin. Which of the following client statements indicates an understanding of the teaching?

• A. I will need to have my INR checked regularly while taking this medication.
• B. I should avoid eating leafy green vegetables while taking this medication.
• C. I will stop taking this medication if I experience nausea.
• D. I will avoid taking aspirin while taking this medication.

Correct answer: A

Rationale: The correct answer is A because clients taking warfarin should have their INR (International Normalized Ratio) checked regularly to monitor the medication's effectiveness and adjust the dose if needed. This monitoring helps to ensure the medication is working correctly and the client is within the therapeutic range. Choice B is incorrect because clients on warfarin should not avoid leafy green vegetables but should maintain a consistent intake. Leafy green vegetables contain vitamin K, which can affect warfarin, so it's important to maintain a consistent intake to keep INR stable. Choice C is incorrect as clients should not stop taking warfarin abruptly without consulting their healthcare provider as it can lead to serious health risks like blood clots. Choice D is incorrect because while taking warfarin, it is important to avoid unnecessary aspirin use due to an increased risk of bleeding. However, this statement does not indicate an understanding of the teaching about the need for regular INR monitoring.

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