Nursing Elites

1. How should the nurse respond to an older male client who states that his religion does not permit him to bathe daily?

• A. Review the importance of hygienic measures for improved health
• B. State that the healthcare provider has prescribed a bath today
• C. Offer the client several choices of times to bathe during the day
• D. Request that the client clarify his religious beliefs about bathing

Correct answer: C

Rationale: The correct response is to offer the client several choices of times to bathe during the day. This approach respects the client's religious beliefs while ensuring that hygienic practices are still maintained. By providing options, the nurse can work together with the client to find a solution that aligns with both his beliefs and his health needs. Choice A is incorrect because solely reviewing the importance of hygiene may not address the client's specific religious concerns. Choice B is inappropriate as it disregards the client's beliefs and autonomy. Choice D is not the best approach as it may come off as confrontational or dismissive of the client's beliefs, rather than working collaboratively to find a suitable solution.

2. A client with a history of hypertension is admitted to the hospital for a suspected myocardial infarction. Which of the following is the priority nursing action?

• A. Administer oxygen as prescribed
• B. Perform an ECG
• C. Obtain a detailed health history
• D. Monitor vital signs regularly

Correct answer: B

Rationale: The priority nursing action in this scenario is to perform an ECG. An ECG is crucial in confirming myocardial infarction promptly and guiding immediate treatment decisions. Administering oxygen as prescribed is important but not the priority over confirming the diagnosis. Obtaining a detailed health history is relevant but does not take precedence over immediate diagnostic confirmation. While monitoring vital signs regularly is essential, performing an ECG is the priority action in this scenario to guide timely management.

3. After placing a client at 26-weeks gestation in the lithotomy position, the client complains of dizziness and becomes pale and diaphoretic. What action should the nurse implement?

• A. Instruct the client to take deep breaths.
• B. Place a wedge under the client's hip.
• C. Place the client in the Trendelenburg position.
• D. Remove the client's legs from the stirrups.

Correct answer: B

Rationale: Placing a wedge under the client's hip is the correct action in this scenario. This helps relieve the pressure on the vena cava, which can become compressed in the lithotomy position during pregnancy, improving circulation and reducing symptoms like dizziness and pallor. Instructing the client to take deep breaths (Choice A) may not address the underlying cause of the symptoms. Placing the client in the Trendelenburg position (Choice C) would worsen the situation by further compressing the vena cava. Removing the client's legs from the stirrups (Choice D) may provide temporary relief but does not address the root cause of the issue.

4. A client with a history of chronic back pain is prescribed oxycodone for pain management. What is the most important instruction the nurse should provide?

• A. Take the medication with food to reduce stomach upset
• B. Avoid operating heavy machinery while taking this medication
• C. Increase physical activity to enhance pain relief
• D. Report any signs of respiratory depression immediately

Correct answer: D

Rationale: The correct answer is D: 'Report any signs of respiratory depression immediately.' Respiratory depression is a severe side effect of opioids like oxycodone and can be life-threatening. It is crucial for the nurse to instruct the client to report any signs such as slow or shallow breathing, difficulty breathing, or confusion. Choice A is incorrect as taking oxycodone with or without food does not significantly affect its efficacy. Choice B is incorrect because avoiding driving is important due to the potential impairment caused by oxycodone, but reporting respiratory depression is more critical. Choice C is incorrect as increasing physical activity may not always be suitable for individuals with chronic back pain and is not directly related to preventing respiratory depression.

5. The nurse is caring for a client postoperatively following a thyroidectomy. Which assessment finding should be reported to the healthcare provider immediately?

• A. Hoarseness of the voice.
• B. Slight swelling at the incision site.
• C. Tingling around the mouth.
• D. Mild fever.

Correct answer: C

Rationale: Tingling around the mouth should be reported to the healthcare provider immediately as it may indicate hypocalcemia, a potential complication after thyroidectomy. Hoarseness of the voice is common postoperatively due to surgical manipulation, slight swelling at the incision site is a normal response, and a mild fever can be expected after surgery. However, tingling around the mouth suggests a potential calcium imbalance, which requires prompt attention to prevent serious complications.

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