Nursing Elites

1. What action should the nurse take for a client struggling to void after having an indwelling catheter removed?

• A. Assess for bladder distention after 2 hours
• B. Encourage the client to try urinating in a sitting position
• C. Pour warm water over the client's perineum
• D. Restrict the client's fluid intake

Correct answer: C

Rationale: The correct action for the nurse to take is to pour warm water over the client's perineum. This intervention helps stimulate urination after catheter removal by providing warmth and promoting relaxation of the muscles. Assessing for bladder distention after 2 hours (Choice A) is not the initial intervention to facilitate voiding. Encouraging the client to try urinating in a sitting position (Choice B) may be uncomfortable if the client is struggling to void. Restricting the client's fluid intake (Choice D) is not appropriate as it can further exacerbate the issue by concentrating the urine.

2. What are the key interventions for managing a patient with asthma?

• A. Administer bronchodilators and monitor oxygen levels
• B. Encourage deep breathing exercises
• C. Provide corticosteroids and monitor for respiratory distress
• D. Provide antihistamines and monitor blood pressure

Correct answer: A

Rationale: The correct answer is A: Administer bronchodilators and monitor oxygen levels. Asthma management involves using bronchodilators to help open the airways and improve breathing. Monitoring oxygen levels is essential to ensure the patient is getting enough oxygen. Choice B, encouraging deep breathing exercises, can be helpful for some respiratory conditions but is not a key intervention for managing an acute asthma attack. Choice C, providing corticosteroids and monitoring for respiratory distress, is important for long-term asthma management and severe exacerbations but is not the immediate key intervention during an acute attack. Choice D, providing antihistamines and monitoring blood pressure, is not typically indicated for asthma management as asthma is primarily an airway disease, not a histamine-mediated condition.

3. Which of the following situations can be identified as an ethical dilemma?

• A. A nurse demonstrates signs of chemical impairment
• B. A family has conflicting feelings about tube feeding for their terminally ill father
• C. A nurse overhears a colleague threatening to restrain a patient if they do not stay in bed
• D. A client with terminal cancer hesitates to name their spouse as power of attorney

Correct answer: B

Rationale: The correct answer is B. Ethical dilemmas involve conflicting values or feelings. In this situation, the family is conflicted about tube feeding for their terminally ill father, which presents a moral and ethical challenge. Choices A, C, and D do not represent ethical dilemmas. Choice A involves a nurse's impairment, which is a different issue. Choice C involves a nurse's observation of a colleague's threat, which is a patient safety concern. Choice D involves a client's hesitation in naming a spouse as power of attorney, which is a legal and decision-making issue, not necessarily an ethical dilemma.

4. What intervention is key when managing a client with delirium?

• A. Administer antipsychotic medication to calm the client
• B. Identify any reversible causes of delirium
• C. Provide a low-stimulation environment
• D. Increase environmental stimulation

Correct answer: B

Rationale: The correct intervention when managing a client with delirium is to identify any reversible causes. Delirium can be caused by various factors such as infections, medications, dehydration, or metabolic imbalances. Administering antipsychotic medications (Choice A) may worsen delirium and should be avoided unless necessary for specific indications. Providing a low-stimulation environment (Choice C) is beneficial as it can help reduce agitation and confusion in individuals with delirium. Increasing environmental stimulation (Choice D) is contraindicated as it can exacerbate symptoms in delirious patients. Therefore, the priority should be on identifying and addressing reversible causes to effectively manage delirium.

5. What are the signs of an acute myocardial infarction?

• A. Chest pain radiating to the arm and shortness of breath
• B. Nausea, vomiting, and high fever
• C. Headache, confusion, and low blood pressure
• D. Increased heart rate and bradycardia

Correct answer: A

Rationale: The correct answer is A: Chest pain radiating to the arm and shortness of breath. These are classic signs of an acute myocardial infarction. Choice B is incorrect because nausea, vomiting, and high fever are not typical signs of a heart attack. Choice C is incorrect as headache, confusion, and low blood pressure are not specific to myocardial infarction. Choice D is incorrect because an acute myocardial infarction typically presents with an increased heart rate, not bradycardia.

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