Nursing Elites

1. What safety measure should the nurse take for a client with a seizure disorder who has an IV line?

• A. Ensure that the IV site is padded and protected.
• B. Limit the client's mobility to prevent dislodging the IV.
• C. Place the IV site on the same side as the seizure activity.
• D. Ensure the client is positioned on the opposite side of the IV line.

Correct answer: D

Rationale: The correct answer is D: Ensure the client is positioned on the opposite side of the IV line. Placing the IV line on the opposite side of any seizure activity is essential to prevent injury. It helps to ensure that the IV line is not dislodged during a seizure. Choices A, B, and C are incorrect. While padding and protecting the IV site is important, the priority is to position the client on the side opposite to the IV line to prevent dislodgement and injury during a seizure.

2. A client with schizophrenia is experiencing paranoia. What is the nurse's priority intervention?

• A. Reassure the client that their fears are unfounded.
• B. Place the client in a private room to reduce stimuli.
• C. Provide the client with a distraction to redirect their attention.
• D. Encourage the client to express their concerns and validate their feelings.

Correct answer: D

Rationale: Encouraging clients with paranoia to express their concerns and validating their feelings is crucial as it helps establish trust and reduce anxiety. This approach also aids in building a therapeutic relationship. Reassuring the client that their fears are unfounded (Choice A) may invalidate their feelings and worsen trust. Placing the client in a private room to reduce stimuli (Choice B) may be helpful in some situations but does not address the underlying issue of paranoia. Providing a distraction (Choice C) may temporarily shift the client's focus but does not address the root cause of the paranoia. Therefore, the priority intervention is to encourage the client to express their concerns and validate their feelings.

3. The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the UAP?

• A. Report any client complaint of pain or discomfort
• B. Weigh the client and report any weight gain
• C. Note and report the client's food and liquid intake during meals and snacks
• D. All of the above

Correct answer: D

Rationale: The UAP can be tasked with reporting complaints, monitoring weight gain, and tracking food and fluid intake, all of which are important in managing a client with Cushing's syndrome. These tasks fall within the UAP's scope of practice. Reporting client complaints helps in early identification of complications, monitoring weight is crucial due to fluid retention in Cushing's syndrome, and tracking food and fluid intake assists in dietary management. Choices A, B, and C are all necessary components of care for a client with Cushing's syndrome, making option D the correct answer.

4. The nurse instructs a client to use an incentive spirometer. The client performs a return demonstration as seen in the video. Which action should the nurse take in response to the return demonstration?

• A. Instruct the client to inhale more deeply
• B. Remind the client to cough after using the spirometer
• C. Praise the client for correct usage
• D. Suggest increasing the frequency of spirometer use

Correct answer: B

Rationale: The correct action for the nurse to take in response to the return demonstration of using an incentive spirometer is to remind the client to cough after using the device. Coughing helps clear secretions from the lungs and promotes lung expansion. Instructing the client to inhale more deeply (Choice A) is not necessary as the primary focus after using the spirometer is to clear secretions. Praising the client for correct usage (Choice C) is positive but does not address the essential step of coughing. Suggesting increasing the frequency of spirometer use (Choice D) is not the immediate action needed after the demonstration.

5. A client with hyperthyroidism is admitted for total thyroidectomy. What is the nurse's priority post-operative intervention?

• A. Monitor the client's calcium levels for hypocalcemia.
• B. Monitor for signs of respiratory distress.
• C. Administer oral calcium supplements.
• D. Elevate the head of the bed to 45 degrees.

Correct answer: A

Rationale: The correct answer is to monitor the client's calcium levels for hypocalcemia. After a total thyroidectomy, there is a risk of accidental removal or damage to the parathyroid glands, leading to hypocalcemia. This complication can manifest within the first 24-48 hours post-op. Monitoring calcium levels is crucial to prevent serious complications such as tetany or seizures. While monitoring for respiratory distress is important, it is not the priority in this case. Administering oral calcium supplements should only be done based on the healthcare provider's prescription and after assessing the client's calcium levels. Elevating the head of the bed to 45 degrees is beneficial for respiratory function but is not the priority intervention for a client at risk for hypocalcemia post-thyroidectomy.

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