Nursing Elites

1. A 4-year-old client is unable to go to sleep at night in the hospital. Which nursing intervention best promotes sleep for the child?

• A. turning off the room light and closing the door
• B. engaging the child in calming activities before bedtime
• C. identifying the child's home bedtime rituals and following them
• D. encouraging relaxation techniques like deep breathing exercises

Correct answer: C

Rationale: For a 4-year-old client struggling to sleep in the hospital, the best nursing intervention is to identify the child's home bedtime rituals and follow them. Preschool-age children often have specific bedtime routines that provide comfort and promote sleep. This familiarity can help create a sense of security in an unfamiliar hospital environment. Choice A, turning off the room light and closing the door, may increase the child's fear of the dark and being alone. Choice B, engaging the child in calming activities before bedtime, is a better choice than tiring them with play exercises. Choice D, encouraging relaxation techniques like deep breathing exercises, although helpful, may not be as effective as following the child's familiar bedtime routines.

2. The nurse is caring for a client recovering from a stroke who recently regained consciousness. The client is having difficulty communicating verbally with the team. Which of the following actions would be least appropriate?

• A. Begin client data collection before receiving the physician's order for the referral.
• B. Use documents to provide information for the referral.
• C. Wait for the physician's order for speech therapy before assisting with the appropriate documentation.
• D. Participate in the client referral process.

Correct answer: C

Rationale: In this scenario, the least appropriate action would be to wait for the physician's order for speech therapy before assisting with the appropriate documentation. The nurse should start by collecting client data without needing the physician's order, use documents to provide information for the referral, and actively participate in the client referral process. Waiting for the physician's order unnecessarily delays potentially crucial therapy for the client's recovery, affecting the timeliness and effectiveness of care. Therefore, choice C is the least appropriate as immediate action is required in such situations.

3. While preparing a client for a bronchoscopy, a nurse notes that the client is wearing a gold necklace. What should the nurse do to safeguard the client's necklace?

• A. Ask the client for permission to lock the necklace in the hospital safe
• B. Ask the client to remove the necklace and place it in the top drawer of the bedside table
• C. Ask the client whether the necklace is gold
• D. Ask the client to sign a release to free the hospital of responsibility if the necklace is damaged or lost during the procedure

Correct answer: A

Rationale: When a client has valuables such as jewelry, the nurse should ensure their safekeeping. It is appropriate for the nurse to ask the client for permission to lock the necklace in the hospital safe to prevent loss or damage. This option prioritizes the security of the necklace while allowing the client to make an informed decision. Asking the client to sign a release form does not guarantee the necklace's safety; it only releases the hospital from liability. Placing the necklace in a bedside table drawer does not provide adequate security as it is not as secure as a hospital safe. Inquiring whether the necklace is gold is irrelevant to safeguarding the jewelry during the procedure, as the primary concern is its safekeeping.

4. When a client is having a seizure and their blood oxygen saturation drops from 92% to 82%, what should the nurse do first?

• A. Open the airway.
• B. Administer oxygen.
• C. Suction the client.
• D. Check for breathing.

Correct answer: A

Rationale: When a client is experiencing a seizure and their blood oxygen saturation drops, the priority action for the nurse is to open the airway. Ensuring a clear airway is essential to maintain oxygenation during a seizure episode. Administering oxygen may be necessary but is secondary to ensuring a patent airway. Suctioning the client should only be done if there is an airway obstruction. Checking for breathing is important, but opening the airway takes precedence to support ventilation and oxygenation.

5. In an obstetrical emergency, which of the following actions should the nurse perform first after the baby delivers?

• A. Place extra padding under the mother to absorb blood from the delivery.
• B. Cut the umbilical cord using sterile scissors.
• C. Suction the baby's mouth and nose.
• D. Wrap the baby in a clean blanket to preserve warmth.

Correct answer: C

Rationale: In an obstetrical emergency, the immediate priority after the baby delivers is to clear the baby's airway by suctioning the mouth and nose to ensure effective breathing. This action helps prevent potential complications like meconium aspiration. Cutting the umbilical cord, wrapping the baby in a blanket, or placing extra padding under the mother can follow once the baby's airway is clear. Therefore, suctioning the baby's mouth and nose is the most critical and time-sensitive intervention in this scenario. Placing extra padding under the mother is not the immediate priority as ensuring the baby's airway is clear. Cutting the umbilical cord and wrapping the baby in a clean blanket are important but can wait until after ensuring the baby's breathing is not compromised.

Similar Questions