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. A nurse is teaching a client about home care following cataract surgery. Which of the following statements should the nurse include?

• A. You should wear a protective eye shield while sleeping.
• B. You should avoid bending over to pick things up.
• C. You should apply pressure to your eye if you feel pain.
• D. You should resume wearing your regular glasses immediately.

Correct answer: A

Rationale: The correct answer is A: 'You should wear a protective eye shield while sleeping.' After cataract surgery, wearing a protective eye shield while sleeping is crucial to prevent accidental injury to the eye. Choice B is incorrect because patients should indeed avoid bending over, but it is not the most important instruction among the options provided. Choice C is incorrect because applying pressure to the eye if pain is felt can be harmful and should not be advised. Choice D is incorrect because patients should not resume wearing their regular glasses immediately post cataract surgery; they should wait until their healthcare provider permits.

3. A client is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take?

• A. Measure the client's blood glucose level every 6 hours
• B. Change the TPN tubing every 24 hours
• C. Weigh the client weekly
• D. Administer the TPN through a peripheral IV line

Correct answer: B

Rationale: The correct action for the nurse to take when caring for a client receiving total parenteral nutrition (TPN) is to change the TPN tubing every 24 hours. This practice helps reduce the risk of infection in clients receiving parenteral nutrition. Measuring the client's blood glucose level every 6 hours is important for clients on insulin therapy or with diabetes, but it is not directly related to TPN administration. Weighing the client weekly is essential for monitoring fluid status and nutritional progress, but it is not specific to TPN care. Administering TPN through a peripheral IV line is incorrect because TPN solutions are hypertonic and can cause phlebitis or thrombosis if administered through a peripheral line; a central venous access is typically used for TPN administration.

4. A nurse in an emergency department is assessing a newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following actions should the nurse take first?

• A. Obtain a baseline ECG
• B. Obtain a blood specimen for ABG analysis
• C. Insert an 18-gauge IV catheter
• D. Administer 100% humidified oxygen

Correct answer: D

Rationale: In a client experiencing drooling and hoarseness following a burn injury, the priority action for the nurse is to administer 100% humidified oxygen. This is crucial to maintain the airway and address respiratory distress, which takes precedence over obtaining an ECG, collecting blood for ABG analysis, or inserting an IV catheter. Providing oxygen therapy is essential in ensuring the client's oxygenation and respiratory function are optimized in this emergency situation.

5. A nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. What dietary instruction should the nurse provide?

• A. Take magnesium hydroxide for indigestion.
• B. Drink at least 3L of fluid daily.
• C. Eat 1g/kg of protein per day.
• D. Consume foods high in potassium.

Correct answer: C

Rationale: For a client with chronic kidney disease receiving hemodialysis, consuming 1g/kg of protein per day is important. This amount helps manage the condition without overburdening the kidneys. Choice A is incorrect because magnesium hydroxide is not specifically recommended for clients with chronic kidney disease. Choice B is not accurate as fluid intake needs to be individualized based on the client's condition and dialysis status. Choice D is incorrect because foods high in potassium should generally be limited for individuals with kidney disease undergoing hemodialysis to prevent hyperkalemia.

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