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 caring for a client who has a pneumothorax and is being treated with a chest tube. Which of the following findings indicates that the lung has re-expanded?

• A. There is no fluctuation in the water seal chamber.
• B. There is continuous bubbling in the suction control chamber.
• C. There is tidaling in the water seal chamber.
• D. The drainage system is positioned at the level of the client's chest.

Correct answer: A

Rationale: The correct answer is A: 'There is no fluctuation in the water seal chamber.' In a client with a pneumothorax being treated with a chest tube, the absence of fluctuation in the water seal chamber indicates that the lung has re-expanded. This finding suggests that there is no air leak from the lung into the pleural space. Choices B and C are incorrect because continuous bubbling in the suction control chamber or tidaling in the water seal chamber would suggest ongoing air leakage, indicating that the lung has not fully re-expanded. Choice D is also incorrect as the position of the drainage system does not directly indicate lung re-expansion.

3. A nurse is caring for a client who has received a new diagnosis of terminal cancer. The client tells the nurse, 'I just want to live long enough to see my child graduate.' The nurse should identify that the client is in which of the following stages of grief?

• A. Denial
• B. Bargaining
• C. Acceptance
• D. Anger

Correct answer: B

Rationale: The client expressing a desire to live long enough to see their child graduate is an example of bargaining, which is a stage of grief where individuals attempt to negotiate for more time or different outcomes. Denial refers to refusing to accept the reality of the situation, acceptance involves coming to terms with the diagnosis, and anger is feeling frustrated and upset about the situation. Therefore, the correct answer is 'Bargaining.'

4. A nurse is caring for a client who is in labor and is receiving oxytocin. Which of the following findings indicates that the nurse should increase the rate of infusion?

• A. Urine output of 20 ml/hr
• B. Montevideo units consistently at 300 mm Hg
• C. FHR pattern with absent variability
• D. Contractions every 5 minutes that last 30 seconds

Correct answer: D

Rationale: The correct answer is D because contractions every 5 minutes that last 30 seconds indicate that the rate of infusion should be increased. This pattern suggests weak contractions or intervals that are too far apart, requiring an adjustment to improve labor progress. Option A is incorrect as a low urine output is not directly related to the need for an increase in the oxytocin infusion rate. Option B, Montevideo units consistently at 300 mm Hg, is incorrect because it is a measure of intrauterine pressure and does not determine the need for an increase in oxytocin infusion. Option C, FHR pattern with absent variability, is incorrect as it may indicate fetal distress but does not specifically relate to the need for adjusting the oxytocin infusion rate.

5. A nurse is caring for a client who has pneumonia. Which of the following findings should the nurse identify as an indication of the effectiveness of the treatment?

• A. Respiratory rate of 24/min
• B. White blood cell count of 15,000/mm3
• C. SpO2 of 95%
• D. Clear breath sounds

Correct answer: D

Rationale: Clear breath sounds are an essential indicator of effective pneumonia treatment as they suggest resolution of the lung infection. A normal respiratory rate (A) indicates adequate breathing but does not directly reflect the effectiveness of pneumonia treatment. An elevated white blood cell count (B) is a sign of infection and may not decrease immediately with treatment. While maintaining an SpO2 of 95% (C) is crucial for oxygenation, it may not directly indicate the effectiveness of pneumonia treatment.

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