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 client has a new diagnosis of hypertension and is being taught about lifestyle changes by a nurse. Which of the following instructions should the nurse include?

• A. Increase your sodium intake to 3,000 mg per day.
• B. Exercise for 30 minutes at least 5 days a week.
• C. Sleep for at least 10 hours each night.
• D. Limit your fluid intake to 1 liter per day.

Correct answer: B

Rationale: The correct answer is B: "Exercise for 30 minutes at least 5 days a week." Regular exercise helps promote cardiovascular health and manage hypertension. Choice A is incorrect because increasing sodium intake is not recommended for hypertension. Choice C is incorrect because while sleep is important, excessive sleep duration is not typically part of hypertension management. Choice D is incorrect because fluid intake should be adequate unless advised otherwise by a healthcare provider.

3. A client with a history of heart failure is receiving furosemide. Which of the following laboratory values should the nurse monitor?

• A. Sodium 140 mEq/L
• B. Calcium 9.0 mg/dL
• C. Potassium 3.2 mEq/L
• D. Chloride 100 mEq/L

Correct answer: C

Rationale: The correct answer is C: Potassium 3.2 mEq/L. A potassium level of 3.2 mEq/L is below the normal range and should be monitored in clients receiving furosemide due to the risk of hypokalemia. Furosemide is a loop diuretic that can cause potassium depletion, leading to hypokalemia. Monitoring potassium levels is crucial to prevent complications such as cardiac arrhythmias. Choices A, B, and D are not directly impacted by furosemide therapy in the same way as potassium levels, making them less relevant for monitoring in this scenario.

4. A nurse is caring for a client who is in a seclusion room following violent behavior. The client continues to display aggressive behavior. Which of the following actions should the nurse take?

• A. Confront the client about this behavior
• B. Express sympathy for the client's situation
• C. Speak assertively to the client
• D. Stand within 30 cm (1 ft) of the client when speaking with them

Correct answer: C

Rationale: In this situation, speaking assertively is the most appropriate action for the nurse to take. Confronting the client may escalate the situation further. Expressing sympathy, although important in other contexts, may not be effective in managing aggressive behavior. Standing within close proximity to an aggressive client can compromise the nurse's safety. Therefore, speaking assertively helps to set clear boundaries and manage the situation while ensuring safety in a seclusion room.

5. A client scheduled for a thoracentesis requires assistance from a nurse. Which of the following actions should the nurse take?

• A. Assist the client to a prone position.
• B. Assist the client to a sitting position.
• C. Assist the client to a supine position.
• D. Assist the client to a lateral position.

Correct answer: B

Rationale: The correct answer is to assist the client to a sitting position. Placing the client in a sitting position helps facilitate easier access during the thoracentesis procedure by allowing gravity to assist in the removal of pleural fluid. Placing the client in a prone, supine, or lateral position would not provide the optimal positioning needed for a thoracentesis and could make the procedure more challenging or uncomfortable for the client.

Similar Questions