Nursing Elites

1. What is the best intervention for a patient experiencing respiratory distress?

• A. Administer oxygen
• B. Administer bronchodilators
• C. Administer IV fluids
• D. Provide chest physiotherapy

Correct answer: A

Rationale: Administering oxygen is the best intervention for a patient experiencing respiratory distress because it helps improve oxygenation and alleviate respiratory distress. Oxygen therapy is crucial in ensuring that the patient receives an adequate supply of oxygen to meet the body's demands. Administering bronchodilators (Choice B) may be beneficial in specific respiratory conditions like asthma or COPD but may not be the primary intervention in all cases of respiratory distress. Administering IV fluids (Choice C) may be necessary in cases of dehydration or shock but would not directly address respiratory distress. Providing chest physiotherapy (Choice D) can help mobilize secretions in conditions like cystic fibrosis but is not the first-line intervention for respiratory distress.

2. A client has a central venous catheter. Which of the following actions should be taken to prevent an air embolism?

• A. Keep the catheter clamped when not in use
• B. Have the client perform the Valsalva maneuver while the catheter is removed
• C. Use a non-coring needle to access the catheter
• D. Flush the catheter with 0.9% sodium chloride every 24 hours

Correct answer: B

Rationale: The correct action to prevent an air embolism in a client with a central venous catheter is to have the client perform the Valsalva maneuver while the catheter is removed. This maneuver helps to close the airway and prevent air from entering the bloodstream. Keeping the catheter clamped at all times (Choice A) is not necessary and may lead to clot formation. Using a non-coring needle (Choice C) is important for accessing the catheter but does not specifically prevent air embolism. Flushing the catheter with 0.9% sodium chloride (Choice D) helps maintain patency but does not directly prevent air embolism.

3. A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take?

• A. Position the client on their left side.
• B. Insert the enema tubing 8 cm (3.1 in) into the client's rectum.
• C. Hold the container of the enema solution 61 cm (24 in) above the client.
• D. Advance the enema tubing 15 cm (6 in) into the client's rectum.

Correct answer: C

Rationale: The correct action the nurse should take when administering a cleansing enema is to hold the container of the enema solution 61 cm (24 in) above the client. This height facilitates the proper flow of the solution into the client's rectum. Positioning the client on their left side helps facilitate the administration process, but it is not the specific action related to the enema solution. Inserting the enema tubing 8 cm (3.1 in) into the rectum is incorrect as it may not deliver the solution effectively. Advancing the enema tubing 15 cm (6 in) into the client's rectum is excessive and could cause trauma.

4. A client requires seclusion to prevent harm to others on the unit. What action should the nurse take?

• A. Offer fluids every 2 hours.
• B. Document the client's behavior prior to being placed in seclusion.
• C. Discuss the client's inappropriate behavior prior to seclusion.
• D. Assess the client's behavior every hour.

Correct answer: B

Rationale: The correct answer is to document the client's behavior prior to being placed in seclusion. Documenting the behavior is crucial as it ensures that the decision to use seclusion is based on appropriate justifications and helps in monitoring the client's progress and response to the intervention. Offering fluids every 2 hours (Choice A) is not directly related to the need for seclusion. Discussing the client's behavior prior to seclusion (Choice C) may not be appropriate at the moment when immediate action is required to prevent harm. Assessing the client's behavior every hour (Choice D) is important but not as immediate as documenting the behavior prior to seclusion.

5. A nurse is teaching a client about the physiological changes that occur with aging. Which of the following findings should the nurse expect?

• A. Decreased sense of taste
• B. Decreased blood pressure
• C. Increased gastric secretions
• D. Increased accommodation to near vision

Correct answer: A

Rationale: The correct answer is A: Decreased sense of taste. As individuals age, they may experience a decrease in their sense of taste due to changes in taste buds and a decrease in saliva production. This can lead to a reduced ability to taste flavors or distinguish between different tastes. Choices B, C, and D are incorrect. Decreased blood pressure is not a consistent physiological change with aging; instead, blood pressure may increase or remain stable. Gastric secretions tend to decrease with age, leading to issues like decreased absorption of certain nutrients. Accommodation to near vision typically decreases with age, causing a condition known as presbyopia, where individuals have difficulty focusing on close objects.

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