Nursing Elites

1. Which intervention should be prioritized for a client experiencing panic-level anxiety?

• A. Postpone health teaching until anxiety subsides
• B. Encourage participation in group therapy
• C. Monitor vital signs every 5 minutes
• D. Provide reassurance and remain with the client

Correct answer: D

Rationale: During panic-level anxiety, the priority is to provide reassurance and remain with the client. This intervention helps to offer immediate support, comfort, and a sense of safety to the client. Postponing health teaching until anxiety subsides (Choice A) is not appropriate as the client's immediate emotional needs are more critical. Encouraging participation in group therapy (Choice B) may be beneficial in the long term but is not the priority during a panic attack. While monitoring vital signs (Choice C) is important, providing reassurance and support take precedence in managing panic-level anxiety.

2. The nurse is caring for a patient with an incision. Which actions will best indicate an understanding of medical and surgical asepsis for a sterile dressing change?

• A. Donning sterile gown and gloves to remove the wound dressing
• B. Utilizing clean gloves to remove the dressing and clean supplies for the new dressing
• C. Utilizing clean gloves to remove the dressing and sterile supplies for the new dressing
• D. Donning clean goggles, gown, and gloves to dress the wound

Correct answer: C

Rationale: Choice C is the correct answer. When performing a sterile dressing change, it is essential to use clean gloves to remove soiled dressings and sterile gloves and supplies for applying the new dressing. This helps maintain aseptic technique and reduce the risk of introducing pathogens to the wound. Choices A, B, and D involve incorrect use of sterile and clean supplies, which can compromise the sterility of the procedure and increase the risk of infection.

3. A health care provider asks the nurse who is caring for a client with a new colostomy to ask the hospital's stoma nurse to visit the client. What is the nurse's responsibility?

• A. Contact the stoma nurse immediately.
• B. Educate the client on stoma care.
• C. Assess the stoma site for complications.
• D. Arrange for follow-up visits with the stoma nurse.

Correct answer: B

Rationale: The correct answer is B: 'Educate the client on stoma care.' The nurse's primary responsibility in this scenario is to provide education to the client on stoma care. This empowers the client to take care of their colostomy effectively. While it is important to involve the stoma nurse for specialized care, the immediate action required from the nurse is client education. Choice A is incorrect as the immediate action is not to contact the stoma nurse but to educate the client first. Choice C is not the nurse's initial responsibility unless there are obvious complications. Choice D is premature as arranging follow-up visits should come after the client has been educated and initial care has been provided.

4. A client who has a new prescription for ferrous sulfate is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should expect dark tarry stools.
• B. I should expect increased bruising.
• C. I will not get as many infections.
• D. I will expect the color of my urine to be amber.

Correct answer: A

Rationale: The correct answer is A. When taking ferrous sulfate, dark tarry stools can occur as a common side effect due to the iron content in the medication. This is a normal response to the medication and not a cause for concern. Choices B, C, and D are incorrect because increased bruising, reduced infections, and amber-colored urine are not expected side effects of ferrous sulfate.

5. A healthcare professional is assessing a client 15 minutes after administering morphine sulfate 2 mg via IV push. The healthcare professional should identify which of the following findings as an adverse effect of the medication?

• A. Drowsy but responsive when her name is called
• B. SaO2 94%
• C. Respiratory rate 8/min
• D. Pain level of 6 on a scale from 0 to 10

Correct answer: C

Rationale: A respiratory rate of 8/min is a significant adverse effect of morphine that indicates respiratory depression, which requires immediate intervention to prevent further complications. The client may not be effectively ventilating, leading to hypoxia and respiratory acidosis. Option A is less concerning as being drowsy but responsive is a common side effect of morphine. Option B indicates decreased oxygen saturation, which is also a concern but not as severe as respiratory depression. Option D is important but not as critical as the potential respiratory compromise indicated by the low respiratory rate.

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