Nursing Elites

1. What is the priority nursing action for a patient with shortness of breath?

• A. Administer oxygen
• B. Reposition the patient
• C. Check oxygen saturation
• D. Elevate the head of the bed

Correct answer: A

Rationale: Administering oxygen is the priority nursing action for a patient experiencing shortness of breath. Oxygen therapy aims to improve oxygenation levels quickly, addressing the underlying cause of the symptom. Repositioning the patient, checking oxygen saturation, and elevating the head of the bed are important interventions but administering oxygen takes precedence in this scenario to ensure adequate oxygen supply to the body.

2. A client is receiving brachytherapy for the treatment of prostate cancer. Which of the following actions should the nurse take?

• A. Cleanse equipment before removal from the client's room
• B. Limit the client's visitors to 30 minutes per day
• C. Discard the client's linens in a double bag
• D. Discard the radioactive source in a biohazard bag

Correct answer: B

Rationale: The correct action the nurse should take when caring for a client receiving brachytherapy is to limit the client's visitors to 30 minutes per day. This is crucial to reduce exposure to radiation and maintain safety during the brachytherapy procedure. Cleansing equipment before removal from the client's room may be important for infection control but is not directly related to brachytherapy procedures. Discarding the client's linens in a double bag and discarding the radioactive source in a biohazard bag are incorrect choices as they do not specifically address the safety measures needed during brachytherapy for prostate cancer.

3. A client with diabetes mellitus is receiving discharge instructions from a nurse. Which statement by the client indicates an understanding of the teaching?

• A. I will monitor my blood sugar level once a week.
• B. I will exercise every day even if my blood sugar is low.
• C. I will eat snacks rich in carbohydrates if my blood sugar drops.
• D. I will avoid sugary foods to prevent my blood sugar from rising.

Correct answer: C

Rationale: The correct answer is C. Eating snacks rich in carbohydrates is essential to manage hypoglycemia by raising blood sugar levels. Option A is incorrect as monitoring blood sugar once a week is not frequent enough for effective diabetes management. Option B is incorrect because exercising when blood sugar is low can worsen hypoglycemia. Option D is incorrect as it focuses on preventing high blood sugar levels, not managing low blood sugar.

4. A nurse is caring for a client who has depression and reports taking St. John's wort along with citalopram. The nurse should monitor the client for which of the following conditions as a result of an interaction between these substances?

• A. Serotonin syndrome
• B. Tardive dyskinesia
• C. Pseudo-parkinsonism
• D. Acute dystonia

Correct answer: A

Rationale: The correct answer is A: Serotonin syndrome. When a client takes St. John's wort, a herbal supplement, along with citalopram, a selective serotonin reuptake inhibitor (SSRI), there is a risk of developing serotonin syndrome. Serotonin syndrome is a potentially life-threatening condition characterized by symptoms such as confusion, agitation, fever, sweating, shivering, tremors, muscle rigidity, and in severe cases, seizures and coma. It is crucial for the nurse to monitor the client for these symptoms. Choices B, C, and D are incorrect because tardive dyskinesia is associated with long-term use of antipsychotic medications, pseudo-parkinsonism is a side effect of antipsychotic medications like haloperidol, and acute dystonia is a side effect of antipsychotic medications characterized by sustained muscle contractions.

5. When documenting an incorrect dose of medication administered, which fact related to the incident report should the nurse document in the client's medical record?

• A. Time the medication was given
• B. The client's response to the medication
• C. The dose that was administered
• D. Reason for the error

Correct answer: A

Rationale: The nurse should document the time the medication was given in the client's medical record when an incorrect dose is administered. Recording the time is crucial for establishing the sequence of events accurately. Choices B, C, and D, though important, are not directly relevant to documenting the incident of administering an incorrect dose of medication. The client's response to the medication, the actual dose administered, and the reason for the error may be documented for overall patient care but are not specifically required in the incident report for an incorrect dose.

Similar Questions