Nursing Elites

1. The nurse is caring for a seated client experiencing a tonic-clonic seizure. Which actions should the nurse implement?

• A. Place a padded tongue depressor in the client's mouth
• B. Restrain the client and attempt to stop the seizure
• C. Begin CPR immediately
• D. Loosen restrictive clothing and ease the client to the floor

Correct answer: D

Rationale: During a tonic-clonic seizure, the nurse should loosen restrictive clothing to prevent injury and ease the client to the floor to ensure safety. Placing any object, such as a tongue depressor, in the client's mouth is contraindicated as it may cause harm. Restraint should not be used as it can lead to injury. Beginning CPR is not indicated during a seizure unless the client experiences cardiac arrest, which is a rare complication of seizures.

2. A client with chronic kidney disease is prescribed a low-sodium diet. What is the nurse's priority teaching?

• A. Choose fresh fruits and vegetables.
• B. Restrict fluid intake to 1500 mL per day.
• C. Limit sodium intake to 2 grams per day.
• D. Increase potassium intake to prevent hypokalemia.

Correct answer: C

Rationale: The correct answer is C: 'Limit sodium intake to 2 grams per day.' For a client with chronic kidney disease, limiting sodium intake is crucial because it helps prevent fluid retention and reduces the workload on the kidneys. Choice A, 'Choose fresh fruits and vegetables,' is generally a healthy dietary recommendation but not the priority when focusing on a low-sodium diet. Choice B, 'Restrict fluid intake to 1500 mL per day,' is important but secondary to limiting sodium intake. Choice D, 'Increase potassium intake to prevent hypokalemia,' is not the priority teaching for a client with chronic kidney disease on a low-sodium diet.

3. To prevent unnecessary hypoxia during suctioning of a tracheostomy, what must the nurse do?

• A. Apply suction for no more than 10 seconds
• B. Maintain sterile technique
• C. Lubricate 3 to 4 inches of the catheter tip
• D. Withdraw catheter in a circular motion

Correct answer: A

Rationale: The correct answer is to apply suction for no more than 10 seconds. Prolonged suctioning can lead to hypoxia, so it is essential to limit the suctioning time. Maintaining sterile technique (choice B) is important to prevent infections but is not directly related to preventing hypoxia during suctioning. Lubricating the catheter tip (choice C) helps with insertion but does not specifically address hypoxia prevention. Withdrawing the catheter in a circular motion (choice D) is not a standard practice during tracheostomy suctioning and does not help prevent hypoxia.

4. A female client experiences a sudden loss of consciousness and is taken to the emergency department. Initial assessment indicates her blood glucose level is critically low. Once stabilized, she reports being treated for anorexia nervosa. What intervention is most important for the nurse to include in the client’s discharge plan?

• A. Encourage a high-protein, low-carbohydrate diet.
• B. Encourage her to join a group focusing on self-esteem.
• C. Schedule an outpatient psychosocial assessment.
• D. Teach relaxation techniques to manage stress.

Correct answer: B

Rationale: Joining a group that focuses on self-esteem is the most important intervention for the nurse to include in the client's discharge plan. This can help the client address underlying emotional issues related to her anorexia nervosa and improve her mental health. Choice A is incorrect because a high-protein, low-carbohydrate diet may not address the psychological factors contributing to anorexia nervosa. Choice C is incorrect as scheduling an outpatient psychosocial assessment is important but not the most crucial intervention for discharge planning in this case. Choice D is also not the priority as teaching relaxation techniques, although beneficial, may not directly address the self-esteem and emotional issues that need to be tackled in this situation.

5. The nurse is developing a teaching plan for a client receiving chemotherapy. Which of the following should be the nurse's first priority?

• A. The client will maintain adequate nutrition.
• B. The client will manage side effects of treatment.
• C. The client will recognize signs and symptoms of infection.
• D. The client will experience a reduction in pain.

Correct answer: C

Rationale: The correct answer is C. Recognizing signs and symptoms of infection should be the nurse's first priority when developing a teaching plan for a client receiving chemotherapy. Chemotherapy often compromises the immune system, making patients more susceptible to infections. Early identification and prompt treatment of infections are crucial to prevent complications. Options A, B, and D are important aspects of care but recognizing signs of infection takes precedence due to the potential life-threatening consequences in clients undergoing chemotherapy treatment.

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