Nursing Elites

1. An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be taken by the nurse is to:

• A. Check the carotid pulse
• B. Deliver 5 abdominal thrusts
• C. Give 2 rescue breaths
• D. Open the client's airway

Correct answer: D

Rationale: In this scenario, the priority is to ensure the client has a clear airway to facilitate breathing. After verifying unresponsiveness and calling for help, the nurse should open the client's airway to aid in maintaining ventilation. Checking the carotid pulse (Choice A) may be important but comes after ensuring a clear airway. Delivering abdominal thrusts (Choice B) is indicated for choking, not for an unresponsive client. Giving rescue breaths (Choice C) is also important but only after the airway has been established.

2. A nurse is caring for an older adult client who becomes agitated when the nurse requests the client’s dentures be removed prior to surgery. Which of the following responses should the nurse make?

• A. You seem worried. Are you concerned someone may see you without your teeth?
• B. Don't worry, it’s just for the surgery.
• C. You need to follow the instructions.
• D. The dentures need to be removed for a reason.

Correct answer: D

Rationale: The correct response is to provide a clear rationale for the request, as stated in option D. By explaining the purpose behind removing the dentures, the nurse helps the client understand the necessity, which can reduce agitation and promote cooperation. Option A demonstrates empathy by addressing the client's potential concern about being seen without dentures but lacks a direct explanation. Option B dismisses the client's feelings with a casual statement that may not address the underlying issue. Option C is authoritarian and lacks empathy, potentially escalating the client's agitation.

3. A nurse is evaluating a client’s use of a cane. What is the correct use?

• A. Client holds the cane on the stronger side of the body.
• B. Client holds the cane on the weaker side of the body.
• C. Client holds the cane in front of the weaker side of the body.
• D. Client holds the cane in front of the stronger side of the body.

Correct answer: A

Rationale: The correct way to use a cane is for the client to hold it on the stronger side of the body. This positioning allows the cane to provide support to the weaker side, assisting with balance and stability. Placing the cane on the weaker side (Choice B) may not provide adequate support and could lead to an increased risk of falls. Holding the cane in front of the weaker side (Choice C) or in front of the stronger side (Choice D) does not optimize the support and stability needed while walking with a cane.

4. Which statement made by a client indicates to the nurse that they may have a thought disorder?

• A. 'I'm so angry about this. Wait until my partner hears about this.'
• B. 'I'm a little confused. What time is it?'
• C. 'I can't find my missing shoes. Have you seen them?'
• D. 'I'm fine. It's my daughter who has the problem.'

Correct answer: C

Rationale: The statement 'I can't find my missing shoes. Have you seen them?' displays disorganized thinking or speech, which is characteristic of a thought disorder. The mention of 'missing shoes' in a context that does not make logical sense suggests a disturbance in thought processes. Choices A, B, and D do not demonstrate disorganized thinking typical of thought disorders. Option A reflects emotional expression, option B indicates mild confusion, and option D shows a redirection of focus to someone else's problem.

5. A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration?

• A. purulent exudate
• B. warmth
• C. skin blanching
• D. bleeding

Correct answer: C

Rationale: Infiltration occurs when the IV fluid leaks into the surrounding tissue instead of entering the bloodstream properly. Skin blanching, swelling, and coolness at the IV site are typical signs of infiltration. Purulent exudate (choice A) is associated with infection, warmth (choice B) can indicate phlebitis, and bleeding (choice D) may occur if the IV catheter punctures a blood vessel.

Similar Questions