Nursing Elites

1. What is the most important instruction for the nurse to provide a client being discharged following treatment for Guillain-Barre syndrome?

• A. Avoid exposure to respiratory infections.
• B. Use relaxation exercises when anxious.
• C. Continue physical therapy at home.
• D. Plan short, frequent rest periods.

Correct answer: A

Rationale: The most critical instruction for a client being discharged following treatment for Guillain-Barre syndrome is to avoid exposure to respiratory infections. Guillain-Barre syndrome can affect the respiratory system, making infections particularly dangerous. While relaxation exercises, physical therapy, and rest periods are beneficial for overall well-being and recovery, preventing respiratory infections takes precedence due to the potential life-threatening complications associated with respiratory compromise in Guillain-Barre syndrome.

2. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which intervention should the nurse implement first?

• A. Administer a bronchodilator as prescribed.
• B. Assess the client's respiratory rate.
• C. Assess the client's oxygen saturation.
• D. Elevate the head of the bed.

Correct answer: C

Rationale: Assessing the client's oxygen saturation is crucial in a client with COPD receiving supplemental oxygen to ensure adequate oxygenation. This assessment helps determine if the current oxygen therapy is effective or if adjustments are necessary. While administering a bronchodilator is important in managing COPD, assessing oxygen saturation takes precedence to address the client's immediate oxygen needs. Assessing the respiratory rate is also important but evaluating oxygen saturation provides more direct information about the client's oxygen status. Elevating the head of the bed can improve ventilation but is not the priority when assessing oxygen saturation in a client with COPD receiving supplemental oxygen.

3. Which statement by the client indicates an understanding of the dietary modifications required with Cushing syndrome?

• A. I should increase my intake of foods high in calcium.
• B. I should avoid foods with high sodium content.
• C. I need to decrease my intake of vitamin D.
• D. I should consume more potassium-rich foods.

Correct answer: B

Rationale: The correct answer is B: 'I should avoid foods with high sodium content.' Clients with Cushing syndrome need to limit their sodium intake to help reduce fluid retention and manage hypertension, which are common complications of the syndrome. Increasing calcium intake (choice A) is not specifically indicated for Cushing syndrome. Decreasing vitamin D intake (choice C) is not a typical dietary modification for this condition. Consuming more potassium-rich foods (choice D) is not a primary focus of dietary modifications for Cushing syndrome.

4. Following a lumbar puncture, a client voices several complaints. What complaint indicates to the nurse that the client is experiencing a complication?

• A. I am having pain in my lower back when I move my legs
• B. My throat hurts when I swallow
• C. I feel sick to my stomach and am going to throw up
• D. I have a headache that gets worse when I sit up

Correct answer: D

Rationale: The correct answer is D. A post-lumbar puncture headache, ranging from mild to severe, may occur as a result of leakage of cerebrospinal fluid at the puncture site. This complication is usually managed by bed rest, analgesics, and hydration. Choices A, B, and C do not directly indicate complications associated with a lumbar puncture. Pain in the lower back when moving legs, a sore throat when swallowing, and nausea with a feeling of vomiting are not typical complications of lumbar puncture.

5. When finding a client sitting on the floor, the nurse calls for help from the unlicensed assistive personnel (UAP). Which task should the nurse ask the UAP to do?

• A. Check for any abrasions or bruises.
• B. Help the client to stand.
• C. Get a blood pressure cuff.
• D. Report the fall to the nurse-manager.

Correct answer: C

Rationale: The correct task for the nurse to ask the unlicensed assistive personnel (UAP) to do in this situation is to "Get a blood pressure cuff." This is important because assessing the client's vital signs, including blood pressure, is crucial after a fall to ensure there are no underlying issues like hypotension. Choices A and B may be important tasks for the nurse to perform as part of the assessment and care of the client. However, in this scenario, the immediate concern should be to check the client's blood pressure. Choice D is not the most urgent task at this time, as assessing the client's condition takes precedence.

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