Nursing Elites

1. A nurse is providing teaching to family members of a client who has dementia. Which of the following instructions should the nurse include?

• A. Establish a toileting schedule for the client.
• B. Use clothing with buttons and zippers.
• C. Discourage physical activity during the day.
• D. Engage the client in activities that increase sensory stimulation.

Correct answer: A

Rationale: The correct answer is A: Establish a toileting schedule for the client. A toileting schedule helps manage incontinence and prevent accidents, promoting client dignity. Choice B is incorrect because clothing with buttons and zippers may be difficult for a client with dementia to manage independently. Choice C is incorrect as physical activity during the day is beneficial for clients with dementia. Choice D is incorrect as activities that increase sensory stimulation may be overwhelming for a client with dementia.

2. A client with heart failure is receiving digoxin. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 78/min.
• B. Vision changes.
• C. Respiratory rate of 16/min.
• D. Blood pressure of 120/80 mm Hg.

Correct answer: B

Rationale: The correct answer is B: Vision changes. Vision changes are a classic sign of digoxin toxicity and should be reported immediately to the provider for further evaluation and management. A heart rate of 78/min, a respiratory rate of 16/min, and a blood pressure of 120/80 mm Hg are within normal ranges and are not typically associated with digoxin toxicity. Therefore, they would not be the priority findings to report in this situation.

3. A nurse is providing discharge teaching to a client who has a new prescription for albuterol. Which of the following instructions should the nurse include?

• A. You should take this medication at bedtime.
• B. You might experience palpitations while taking this medication.
• C. You should rinse your mouth after using this medication.
• D. You should avoid eating before taking this medication.

Correct answer: C

Rationale: The correct answer is C: 'You should rinse your mouth after using this medication.' When providing discharge teaching for a client prescribed albuterol, the nurse should include the instruction to rinse the mouth after each use. This is important to prevent dry mouth and oral infections. Choice A is incorrect as albuterol is usually taken during the day to manage symptoms, not at bedtime. Choice B is incorrect as palpitations are not a common side effect of albuterol. Choice D is incorrect as there is no specific requirement to avoid eating before taking albuterol.

4. A nurse is caring for a client who is in a seclusion room following violent behavior. The client continues to display aggressive behavior. Which of the following actions should the nurse take?

• A. Confront the client about this behavior
• B. Express sympathy for the client's situation
• C. Speak assertively to the client
• D. Stand within 30 cm (1 ft) of the client when speaking with them

Correct answer: C

Rationale: In this situation, speaking assertively is the most appropriate action for the nurse to take. Confronting the client may escalate the situation further. Expressing sympathy, although important in other contexts, may not be effective in managing aggressive behavior. Standing within close proximity to an aggressive client can compromise the nurse's safety. Therefore, speaking assertively helps to set clear boundaries and manage the situation while ensuring safety in a seclusion room.

5. A nurse is caring for a client who is 1 day postoperative following a total knee replacement. The client reports pain of 8 on a scale of 0 to 10. Which of the following actions should the nurse take?

• A. Administer ibuprofen 400 mg PO
• B. Administer oxycodone 10 mg PO
• C. Reposition the client to the unaffected side
• D. Apply a cold compress to the affected knee

Correct answer: B

Rationale: In this scenario, the appropriate action for the nurse to take when a client reports severe postoperative pain of 8 out of 10 is to administer oxycodone 10 mg PO. Oxycodone is a potent analgesic that is more effective in managing severe pain compared to ibuprofen, making choice A incorrect. Repositioning the client to the unaffected side or applying a cold compress may provide some comfort but are not the priority interventions for severe postoperative pain, making choices C and D less appropriate.

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