Nursing Elites

1. A client with a history of seizures is being cared for by a nurse. Which of the following interventions should the nurse prioritize?

• A. Ensure the environment is safe
• B. Administer medications as prescribed
• C. Monitor for signs of infection
• D. Educate the client about triggers

Correct answer: A

Rationale: The nurse should prioritize ensuring the environment is safe for a client with a history of seizures. This intervention is crucial to prevent injury during a seizure. Administering medications as prescribed is important but ensuring a safe environment takes precedence to prevent harm. Monitoring for signs of infection and educating the client about triggers are also essential aspects of care but are not the priority when considering the immediate safety of the client during a seizure.

2. A nurse is reviewing information about advance directives with a newly admitted client. Which statement by the client indicates an understanding of the teaching?

• A. My family can make decisions if I am unable to.
• B. I have a living will that outlines my wishes when I am unable to make a decision.
• C. I can write down my wishes, but they aren't legally binding.
• D. I don't need to worry about this until I’m critically ill.

Correct answer: B

Rationale: Choice B is the correct answer because having a living will is a legal document that outlines a client's wishes when they are unable to make decisions, indicating a good understanding of advance directives. Choice A is incorrect because it doesn't mention a specific document like a living will. Choice C is incorrect because advance directives, like a living will, can be legally binding. Choice D is incorrect because planning for advance directives should ideally be done before a person becomes critically ill.

3. A nurse is teaching a client who has hypertension about dietary modifications to help control blood pressure. Which of the following food choices should the nurse recommend as the best choice for the client to include in their diet?

• A. 1 packet of reconstituted dry onion soup
• B. 3 oz of lean cured ham
• C. 3 oz of chicken breast
• D. 1/2 cup of canned baked beans

Correct answer: C

Rationale: A low sodium diet is recommended for a client who has hypertension. Therefore, the nurse should recommend 3 oz of chicken breast as the best choice for the client's diet because it contains 30 – 90 mg of sodium. Choice A, 1 packet of reconstituted dry onion soup, and Choice B, 3 oz of lean cured ham, are high in sodium content, which is not suitable for a client with hypertension. Choice D, 1/2 cup of canned baked beans, is also high in sodium, making it a less suitable choice compared to 3 oz of chicken breast.

4. A nurse is caring for a client with deep vein thrombosis (DVT). Which action should the nurse take?

• A. Position the client with the affected extremity lower than the heart
• B. Administer acetaminophen for pain
• C. Massage the affected extremity every 4 hours
• D. Withhold heparin IV infusion

Correct answer: D

Rationale: Withholding heparin IV infusion is the priority if there is a risk of complications such as bleeding, which must be evaluated before continuing treatment.

5. In the nursing process, the evaluation phase is used to determine:

• A. Value of the nursing intervention
• B. Accuracy of problem identification
• C. Quality of the plan of care
• D. Degree of outcome achievement

Correct answer: D

Rationale: The evaluation phase of the nursing process is used to determine the degree of outcome achievement. It assesses whether the goals and outcomes set during the planning phase were met. Choice A is incorrect because it focuses on the worth of the intervention rather than the achievement of outcomes. Choice B is incorrect as it pertains to the assessment phase where problems are identified. Choice C is incorrect as it refers to the planning phase where the care plan is developed, not evaluated.

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