Nursing Elites

1. The nurse enters a client's room and observes the unlicensed assistive personnel (UAP) making an occupied bed. What action should the nurse take first?

• A. Place the side rails in an up position.
• B. Assist the UAP in turning the client.
• C. Provide instructions on proper bed-making techniques.
• D. Ask the client if they are comfortable.

Correct answer: A

Rationale: The correct answer is to place the side rails in an up position first. This action is essential to prevent the client from falling while the bed is being made. Assisting the UAP in turning the client (Choice B) is not the immediate priority. Providing instructions on bed-making techniques (Choice C) can wait until the safety of the client is ensured. Asking the client if they are comfortable (Choice D) is important but should come after ensuring the client's safety by raising the side rails.

2. A client with newly diagnosed hypertension is being taught about lifestyle modifications by a nurse. Which client statement indicates a need for further teaching?

• A. ‘I will reduce my salt intake to help manage my blood pressure.’
• B. ‘I will start exercising regularly to help control my blood pressure.’
• C. ‘I will avoid drinking alcohol to help manage my blood pressure.’
• D. ‘I will limit my caffeine intake to help control my blood pressure.’

Correct answer: D

Rationale: The correct answer is D. Limiting caffeine intake is a positive lifestyle modification for managing hypertension. The statement indicates that the client understands the importance of reducing caffeine intake. Choices A, B, and C all reflect appropriate lifestyle modifications for managing hypertension, indicating good understanding by the client.

3. After receiving lactulose, a client with hepatic encephalopathy has several loose stools. What action should the nurse implement?

• A. Send stool specimen to the lab
• B. Measure abdominal girth
• C. Encourage increased fiber in the diet
• D. Monitor mental status

Correct answer: D

Rationale: The correct action for the nurse to implement after a client with hepatic encephalopathy has loose stools following lactulose administration is to monitor the client's mental status. Lactulose is given to lower serum ammonia levels in hepatic encephalopathy, and loose stools can be an expected side effect of its use. Monitoring mental status is crucial because changes in mental status, such as confusion or altered level of consciousness, are key indicators of hepatic encephalopathy worsening. Sending a stool specimen to the lab would not be the priority in this situation as loose stools are a known effect of lactulose. Measuring abdominal girth is more relevant for conditions like ascites, not loose stools. Encouraging increased fiber in the diet may be beneficial for constipation but is not the immediate action needed when loose stools occur after lactulose administration.

4. The nurse is assessing a client with left-sided heart failure. Which assessment finding is most concerning?

• A. Jugular venous distention
• B. Peripheral edema
• C. Shortness of breath
• D. Crackles in the lungs

Correct answer: C

Rationale: Shortness of breath is the most concerning finding in a client with left-sided heart failure as it indicates worsening pulmonary congestion and impaired gas exchange. This symptom suggests that the client is experiencing significant difficulty in breathing and inadequate oxygenation, requiring immediate intervention. Jugular venous distention (Choice A) is often seen in right-sided heart failure, while peripheral edema (Choice B) and crackles in the lungs (Choice D) are common manifestations of left-sided heart failure but are not as acutely concerning as severe shortness of breath, which can rapidly progress to respiratory distress if not addressed promptly.

5. While taking vital signs, a critically ill male client grabs the nurse's hand and asks the nurse not to leave. What action is best for the nurse to take?

• A. Pull up a chair and sit beside the client's bed.
• B. Reassure the client that you will return shortly.
• C. Ask another nurse to stay with the client.
• D. Continue taking vital signs and then leave the room.

Correct answer: A

Rationale: The best action for the nurse to take in this situation is to pull up a chair and sit beside the client's bed. By doing so, the nurse can provide emotional support and comfort to the critically ill patient who is feeling vulnerable. Sitting with the client also shows empathy and a willingness to listen to the client's needs. Reassuring the client that the nurse will return shortly (Choice B) may not address the immediate need for emotional support. Asking another nurse to stay with the client (Choice C) may not establish the same level of connection and comfort as sitting with the client personally. Continuing to take vital signs and then leaving the room (Choice D) disregards the client's emotional needs in that moment.

Similar Questions