Nursing Elites

1. A nurse is preparing to administer a rectal suppository to a school-age child. Which of the following actions should the nurse plan to take?

• A. Insert the suppository 1 cm into the rectum
• B. Insert the suppository 2 cm into the rectum
• C. Insert the suppository past the anal sphincters
• D. Insert the suppository using two fingers

Correct answer: C

Rationale: The correct answer is C: 'Insert the suppository past the anal sphincters.' When administering a rectal suppository, it is essential to insert it past the anal sphincters to ensure proper placement and absorption. Choices A and B are incorrect because the suppository should be inserted further than just 1 or 2 cm into the rectum to reach the optimal absorption site. Choice D is incorrect as using two fingers is not necessary and may cause discomfort to the child.

2. What is the first step in managing a client with delirium?

• A. Administer sedative medication to calm the client
• B. Identify any reversible causes of delirium
• C. Limit environmental stimulation to reduce anxiety
• D. Administer antipsychotic medication to control behavior

Correct answer: B

Rationale: The correct first step in managing a client with delirium is to identify any reversible causes of delirium. This is crucial because addressing the underlying cause can help in resolving delirium more effectively. Administering sedative or antipsychotic medications without addressing the root cause may not be helpful and can even worsen the condition. Limiting environmental stimulation, although important, is not the primary step in managing delirium.

3. What are the early signs of sepsis in a patient?

• A. Increased heart rate and fever
• B. Low blood pressure and confusion
• C. Elevated blood sugar and sweating
• D. Increased urine output and abdominal pain

Correct answer: A

Rationale: The correct answer is A: Increased heart rate and fever. These are early signs of sepsis and indicate a systemic infection. It is crucial to identify these signs promptly to initiate appropriate treatment. Choice B is incorrect because low blood pressure and confusion are more indicative of severe sepsis or septic shock rather than early signs. Choice C is incorrect as elevated blood sugar and sweating are not typical early signs of sepsis. Choice D is also incorrect as increased urine output and abdominal pain are not early signs of sepsis.

4. A nurse in a long-term care facility is serving on the ethics committee, which is addressing a client care dilemma. Which of the following strategies will facilitate resolving the dilemma?

• A. Ensure client autonomy only
• B. Consider only medical benefits
• C. Ensure clear communication among the health care team
• D. Identify possible solutions

Correct answer: D

Rationale: In resolving ethical dilemmas, it is essential to identify possible solutions to address the client care dilemma effectively. Option A, 'Ensure client autonomy only,' is not comprehensive enough to resolve complex ethical issues. Option B, 'Consider only medical benefits,' overlooks other important factors beyond medical benefits that are involved in ethical decision-making. Option C, 'Ensure clear communication among the health care team,' is important but may not be sufficient on its own to resolve the ethical dilemma. Therefore, the most effective strategy among the given options is to identify possible solutions to navigate through the ethical dilemma.

5. Which dietary advice should a healthcare provider provide to a client with acute gout?

• A. Increase intake of dairy products
• B. Limit intake of red meat and shellfish
• C. Limit intake of fresh fruits and vegetables
• D. Limit intake of fruit juices and milk

Correct answer: B

Rationale: The correct dietary advice for a client with acute gout is to limit the intake of red meat and shellfish. These foods are high in purines, which can lead to increased uric acid levels in the body, exacerbating gout symptoms. Dairy products, fresh fruits, and vegetables are generally recommended for individuals with gout as they can help lower uric acid levels. Fruit juices and milk, in moderation, can also be part of a gout-friendly diet as they do not significantly contribute to uric acid buildup.

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