Nursing Elites

1. A nurse is preparing to administer a medication to a client. The client states, 'I'm sick of all these medications, and I'm not taking any more today!' Which of the following actions should the nurse take?

• A. Ask the client to discuss their feelings
• B. Explain the importance of the medications
• C. Document the refusal and withhold the medication
• D. Inform the client of the possible consequences of refusal

Correct answer: D

Rationale: When a client refuses medication, the nurse should inform the client of the possible consequences of refusal. This action helps the client understand the risks associated with not taking the medication. Asking the client to discuss their feelings (choice A) is important but should follow after informing them of the consequences. Explaining the importance of the medications (choice B) might not address the immediate concern of the client. Documenting the refusal and withholding the medication (choice C) should be done after informing the client of the consequences and attempting to address their concerns.

2. A client is reinforcing teaching with a nurse about how to use an incentive spirometer. Which of the following actions by the client indicates an understanding of the teaching?

• A. The client exhales deeply before inhaling
• B. The client attempts to elevate the cylinder by inhaling deeply
• C. The client inhales quickly through the spirometer
• D. The client inhales several short breaths

Correct answer: B

Rationale: The correct answer is B because inhaling deeply and slowly elevates the cylinder on the spirometer, promoting lung expansion. Choice A is incorrect as exhaling deeply before inhaling is not the correct technique for using an incentive spirometer. Choice C is incorrect as inhaling quickly through the spirometer does not promote optimal lung expansion. Choice D is incorrect as inhaling several short breaths does not facilitate the proper use of an incentive spirometer.

3. Which intervention should be included for a client with heart failure?

• A. Encourage increased fluid intake
• B. Weigh the client daily to monitor fluid balance
• C. Restrict fluid intake during meals
• D. Limit daily activity to prevent fatigue

Correct answer: B

Rationale: Weighing the client daily to monitor fluid balance is crucial for clients with heart failure. This intervention helps assess for fluid retention or depletion, providing valuable information for managing the condition effectively. Encouraging increased fluid intake (Choice A) is contraindicated in heart failure as it can worsen fluid overload. Restricting fluid intake during meals (Choice C) may lead to dehydration, which is harmful for clients with heart failure. Limiting daily activity (Choice D) is not recommended as appropriate activity levels should be encouraged for overall well-being, under guidance to prevent excessive fatigue.

4. What is the proper technique for obtaining a blood specimen from a central venous line?

• A. Use sterile gloves and discard the first 10 mL of blood
• B. Flush the line with heparin and then draw the specimen
• C. Draw the specimen and then administer heparin
• D. Use non-sterile gloves to reduce contamination risk

Correct answer: A

Rationale: The correct technique for obtaining a blood specimen from a central venous line is to use sterile gloves and discard the first 10 mL of blood. This practice helps ensure that the blood sample collected is not contaminated. Choice B is incorrect because flushing the line with heparin before drawing the specimen can contaminate the sample. Choice C is incorrect as administering heparin before drawing the specimen can affect the accuracy of the blood sample. Choice D is incorrect as using non-sterile gloves increases the risk of contamination, which is not recommended when obtaining a blood specimen from a central venous line.

5. Which instruction is crucial for a client with diabetes being discharged?

• A. Take insulin only when feeling unwell
• B. Administer insulin before meals as prescribed
• C. Monitor blood sugar levels weekly
• D. Check blood sugar once in the morning

Correct answer: B

Rationale: Administering insulin before meals as prescribed is crucial for a client with diabetes being discharged because it ensures proper blood sugar control. Choice A is incorrect because insulin should not be taken only when feeling unwell; it should be taken as prescribed. Choice C is incorrect as monitoring blood sugar levels weekly may not provide timely adjustments to insulin doses. Choice D is incorrect as checking blood sugar only once in the morning is not sufficient for proper diabetes management.

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