Nursing Elites

1. To reduce the risk of symptoms exacerbation for a client with multiple sclerosis (MS), which instructions should the nurse include in the client’s discharge plan? (Select all that apply).

• A. Practice relaxation exercises
• B. Limit fluids to avoid bladder distention
• C. Space activities to allow for rest periods
• D. Avoid persons with infections

Correct answer: A

Rationale: The correct instruction to include in the discharge plan for a client with MS to reduce symptom exacerbation is practicing relaxation exercises. Relaxation exercises can help manage MS symptoms by reducing stress. Limiting fluids to avoid bladder distention is not appropriate as adequate hydration is essential for overall health and helps prevent complications like urinary tract infections. While spacing activities to allow for rest periods can be beneficial for general well-being, it is not directly related to symptom exacerbation in MS. Avoiding persons with infections is important to prevent infections, but it is not specifically targeted at reducing MS symptom exacerbation.

2. A client with a prescription for “do not resuscitate” (DNR) begins to manifest signs of impending death. After notifying the family of the client’s status, what priority action should the nurse implement?

• A. Assess the client’s need for pain medication
• B. Document the impending signs of death
• C. Inform the nurse manager of the client’s status
• D. Communicate the client’s status to the chaplain

Correct answer: A

Rationale: Assessing the client’s need for pain medication is the priority action as it ensures comfort at the end of life. Pain management is crucial in providing comfort and dignity to clients during their final moments. Documenting impending signs of death (choice B) is important but not the immediate priority over addressing the client's comfort. Updating the nurse manager (choice C) and informing the chaplain (choice D) can follow once the client's immediate needs are met.

3. A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, and is exhibiting signs of restlessness. Which action should the nurse take first?

• A. Review the heart rhythm on cardiac monitors
• B. Check urinary catheter for obstruction
• C. Auscultate bilateral breath sounds
• D. Give PRN dose of lorazepam (Ativan)

Correct answer: B

Rationale: When a client in the intensive care unit is mechanically ventilated, has an indwelling urinary catheter, and is restless, the priority action is to check the urinary catheter for obstruction. Restlessness in this context could be due to a blocked catheter causing discomfort or urinary retention, which needs immediate attention to prevent complications. Reviewing the heart rhythm on cardiac monitors can be important but is not the priority in this scenario. Auscultating bilateral breath sounds is also important in a ventilated client but addressing the potential immediate issue of a blocked catheter takes precedence. Giving a PRN dose of lorazepam should not be the first action without addressing the underlying cause of restlessness.

4. After the diagnosis and initial treatment of a 3-year-old with Cystic fibrosis, the nurse provides home care instructions to the mother. Which statement by the child's mother indicates that she understands home care treatment to promote pulmonary functions?

• A. Chest physiotherapy should be performed twice a day before a meal
• B. Energy should be conserved by scheduling minimally strenuous activities
• C. Administer a cough suppressant every 8 hours
• D. Maintain supplemental oxygen at 4 to 6 L/minute

Correct answer: A

Rationale: The correct answer is A. Chest physiotherapy is essential for maintaining pulmonary function in cystic fibrosis. It should be performed regularly, often twice daily, to clear mucus from the lungs. Choice B is incorrect because conserving energy does not directly promote pulmonary function. Choice C is incorrect as cough suppressants are not typically used to promote pulmonary function in cystic fibrosis. Choice D is incorrect as maintaining supplemental oxygen at 4 to 6 L/minute is not a standard home care treatment for promoting pulmonary functions in cystic fibrosis.

5. A school nurse is called to the soccer field because a child has a nosebleed (epistaxis). In what position should the nurse place the child?

• A. Sitting up and leaning forward
• B. Reclining with head elevated
• C. Sitting up with head tilted back
• D. Lying flat on the back

Correct answer: A

Rationale: The correct position for a child with a nosebleed (epistaxis) is sitting up and leaning forward. This position helps prevent blood from flowing into the throat and causing choking. Choice B, reclining with the head elevated, and choice D, lying flat on the back, are incorrect as they can cause blood to flow backward into the throat. Choice C, sitting up with the head tilted back, is also incorrect as it can lead to blood flowing down the back of the throat and potentially into the airway.

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