Nursing Elites

1. When providing discharge instructions for a client with home oxygen, what safety measure should the nurse emphasize?

• A. Prohibit smoking near oxygen equipment
• B. Ensure the client uses non-flammable bedding
• C. Ensure oxygen tanks are stored upright
• D. Keep the oxygen equipment at least 6 feet away from heat sources

Correct answer: D

Rationale: The correct answer is to keep the oxygen equipment at least 6 feet away from heat sources. Placing oxygen equipment near heat sources can lead to fire hazards due to the oxygen's combustible nature. Option A is the correct safety measure as smoking near oxygen equipment can cause fires due to oxygen's flammable properties. Option B regarding the use of non-flammable bedding is not directly related to oxygen safety. Option C is important for proper oxygen tank functioning but is not as critical as keeping the equipment away from heat sources to prevent fires.

2. The nurse is making a home visit with a client diagnosed with Alzheimer's disease. The client recently started on lorazepam (Ativan) due to increased anxiety. The nurse is cautioning the family about the use of lorazepam (Ativan). The nurse should instruct the family to report which of the following significant side effects to the healthcare provider?

• A. Paradoxical excitement
• B. Headache
• C. Slowing of reflexes
• D. Fatigue

Correct answer: A

Rationale: The correct answer is A, paradoxical excitement. Lorazepam can cause an unexpected response of paradoxical excitement, which should be reported to the healthcare provider. This reaction is characterized by increased anxiety, restlessness, and agitation instead of the expected calming effect. Choices B, C, and D are incorrect because headache, slowing of reflexes, and fatigue are more common side effects of lorazepam and may not warrant immediate reporting unless severe or persistent.

3. A nurse is reinforcing discharge teaching with a client who is postoperative following an open radical prostatectomy. Which of the following instructions should the nurse include in the teaching?

• A. Perform Kegel exercises daily
• B. Perform light exercise for 3 hours each day
• C. Avoid bathing for 3 days
• D. Avoid sitting in a chair for more than 2 hours

Correct answer: A

Rationale: The correct answer is A: Perform Kegel exercises daily. After a radical prostatectomy, Kegel exercises are beneficial as they help strengthen the pelvic floor muscles, aiding in urinary control and recovery. Choice B is incorrect because recommending 3 hours of light exercise daily may not be suitable immediately postoperatively. Choice C is incorrect as personal hygiene, including bathing, is important for postoperative care. Choice D is incorrect because sitting for more than 2 hours does not specifically relate to the client's postoperative care needs.

4. What is the most appropriate strategy for a client with an NG tube who is experiencing nausea and decreased gastric secretions?

• A. Increase the suction pressure
• B. Irrigate the NG tube with sterile water
• C. Turn the client onto their side
• D. Replace the NG tube with a new one

Correct answer: B

Rationale: Irrigating the NG tube with sterile water is the most appropriate strategy for a client with an NG tube experiencing nausea and decreased gastric secretions. This intervention helps in relieving blockages within the tube and can help reduce nausea by ensuring proper drainage. Increasing the suction pressure (Choice A) can lead to complications and should not be done without healthcare provider orders. Turning the client onto their side (Choice C) is a general measure for patient comfort but does not directly address the issue with the NG tube. Replacing the NG tube with a new one (Choice D) is not necessary unless there are specific indications like tube damage or dislodgement.

5. Which instruction should be emphasized for a client with diabetes being discharged?

• A. Check blood sugar once daily
• B. Take insulin before meals as prescribed
• C. Monitor glucose levels weekly
• D. Eat carbohydrate-rich meals to maintain glucose levels

Correct answer: B

Rationale: The correct answer is to 'Take insulin before meals as prescribed' because it is crucial for managing blood glucose levels effectively in clients with diabetes. Insulin helps the body utilize glucose from the food consumed, preventing high blood sugar levels. Checking blood sugar once daily (Choice A) may not be sufficient for proper management, as blood sugar levels can fluctuate throughout the day. Monitoring glucose levels weekly (Choice C) is too infrequent and may lead to missed opportunities for timely intervention. Eating carbohydrate-rich meals to maintain glucose levels (Choice D) is not appropriate advice, as it can cause rapid spikes in blood sugar levels, especially without the proper insulin dosage.

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