Nursing Elites

1. While caring for a client who, while sitting in a chair, starts to experience a seizure, what action should the nurse take?

• A. Lower the client to the floor and place a pad under the client's head.
• B. Hold the client's head still to prevent injury.
• C. Restrain the client to prevent movement.
• D. Place the client in a supine position.

Correct answer: A

Rationale: During a seizure, the priority is to lower the client to the floor to prevent injury and ensure their safety. Placing a pad under the client's head helps protect the head from injury. Choice B, holding the client's head still, is incorrect as it can lead to harm; it's essential to allow movement during a seizure to prevent neck injury. Choice C, restraining the client, is dangerous and can cause harm by restricting movement. Choice D, placing the client in a supine position, is also not recommended during a seizure as it does not provide adequate protection for the client.

2. A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first?

• A. Remove the safety pin from the extinguisher.
• B. Aim the extinguisher at the base of the fire.
• C. Squeeze the handle to release the extinguishing agent.
• D. Sweep the extinguisher from side to side.

Correct answer: A

Rationale: The correct first step in using a fire extinguisher is to remove the safety pin. This action enables the extinguisher to be activated and used effectively. Choice B, aiming the extinguisher at the base of the fire, comes after removing the safety pin. Choice C, squeezing the handle to release the extinguishing agent, and choice D, sweeping the extinguisher from side to side, are subsequent steps in using a fire extinguisher and should follow removing the safety pin.

3. During auscultation of a client experiencing chest pain worsened by inspiration, a nurse hears a high-pitched scratching sound in both systole and diastole with the diaphragm of the stethoscope placed at the left sternal border. Which of the following heart sounds should the nurse document?

• A. Pericardial friction rub
• B. Murmur
• C. S1 and S2
• D. Bruit

Correct answer: A

Rationale: The correct answer is 'Pericardial friction rub.' A pericardial friction rub is a high-pitched, scratching sound heard in both systole and diastole, which is characteristic of pericardial inflammation. This sound is different from a murmur, which is a swooshing or blowing sound due to turbulent blood flow. S1 and S2 are normal heart sounds, and a bruit is a whooshing sound caused by turbulent blood flow in an artery, not related to pericardial inflammation.

4. A client is having difficulty breathing while laying in bed with a nasal cannula delivering oxygen. Which of the following interventions should the nurse take first?

• A. Suction the client's airway
• B. Administer a bronchodilator
• C. Increase the humidity in the client's room
• D. Assist the client to an upright position

Correct answer: D

Rationale: The correct answer is to assist the client to an upright position. When a client is having difficulty breathing, promoting optimal oxygenation is essential. Elevating the head of the bed improves ventilation and lung expansion by reducing pressure on the diaphragm. This position allows the lungs to expand fully, enhancing oxygen exchange. Suctioning the airway may be necessary if there are secretions causing obstruction, but it is not the first intervention in this scenario. Administering a bronchodilator is appropriate for bronchoconstriction but does not address the immediate need for better ventilation. Increasing humidity can be beneficial in certain respiratory conditions, but it is not the initial priority when a client is struggling to breathe.

5. A client with diabetes mellitus and a new prescription for insulin is being discharged. Which of the following actions should the nurse plan to complete first?

• A. Provide the client with printed information on insulin self-administration.
• B. Obtain printed information on insulin self-administration.
• C. Make a copy of the medication reconciliation form for the client.
• D. Determine whether the client can afford the insulin administration supplies.

Correct answer: B

Rationale: Obtaining printed information on insulin self-administration should be the nurse's first priority. This action ensures that the client has the necessary knowledge to safely self-administer insulin at home. Providing the client with printed information (Choice A) is essential to empower the client with the required knowledge before considering additional resources. Making a copy of the medication reconciliation form for the client (Choice C) is important for documentation purposes but not as urgent as ensuring the client's understanding of insulin administration. Determining the client's ability to afford insulin administration supplies (Choice D) is crucial but should follow after ensuring the client is equipped with the necessary information for safe self-administration.

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