Nursing Elites

1. Which nursing action is best when managing a client with severe anxiety?

• A. Maintain a calm manner
• B. Help the client identify thoughts prior to the anxiety
• C. Administer anti-anxiety medication
• D. Initiate seclusion if anxiety escalates

Correct answer: A

Rationale: The correct answer is to maintain a calm manner. When managing a client with severe anxiety, the nurse's calm presence can help the client feel more secure and reduce their anxiety levels. It is essential to create a safe and supportive environment. Helping the client identify thoughts prior to anxiety (choice B) may be beneficial in cognitive-behavioral interventions but may not be the initial best action for severe anxiety. Administering anti-anxiety medication (choice C) should be done by a healthcare provider's order and is not the first-line intervention for managing severe anxiety. Initiating seclusion (choice D) should only be considered as a last resort if the client is at risk of harm to themselves or others, as it can further escalate anxiety and should not be the initial action.

2. What is an important consideration in managing a patient with heart failure?

• A. Monitor daily weight
• B. Provide oxygen therapy
• C. Encourage low-sodium diet
• D. Monitor for signs of fluid overload

Correct answer: A

Rationale: The most important consideration in managing a patient with heart failure is to monitor daily weight. This allows healthcare providers to assess fluid retention, adjust medications based on weight changes, and detect early signs of worsening heart failure. While oxygen therapy may be necessary in acute situations, it is not a routine management strategy for stable heart failure patients. Encouraging a low-sodium diet is important to manage fluid retention, but daily weight monitoring is a more direct measure of fluid status. Monitoring for signs of fluid overload is essential, but monitoring daily weight is a proactive approach to detect fluid accumulation before overt symptoms appear.

3. A client who is to undergo surgery for a hip fracture is being taught by a nurse about postoperative pain management. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will ask for pain medication only if the pain becomes unbearable.
• B. I will ask the nurse to increase my medication if the pain doesn't subside.
• C. I will wait until the pain is severe before taking my medication.
• D. I will take my medication at regular intervals to stay ahead of the pain.

Correct answer: D

Rationale: The correct answer is D because taking pain medication at regular intervals helps maintain consistent pain control after surgery. Option A is incorrect because waiting for the pain to become unbearable can lead to inadequate pain management. Option B is incorrect as it suggests increasing medication without a schedule. Option C is incorrect because waiting for the pain to be severe before taking medication is not proactive pain management.

4. A client has undergone a bronchoscopy, and a nurse is providing care post-procedure. What should the nurse do first?

• A. Monitor the client's oxygen levels
• B. Encourage the client to eat
• C. Check for a gag reflex
• D. Administer IV fluids

Correct answer: C

Rationale: After a bronchoscopy, the nurse's priority is to check for a gag reflex. This action helps assess the client's ability to protect their airway after sedation. Maintaining airway patency is crucial post-procedure. Monitoring oxygen levels is important but ensuring airway protection takes precedence. Encouraging the client to eat and administering IV fluids are essential aspects of care but are not the immediate priority in this situation.

5. A client has a prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include in the teaching?

• A. Place the tablet under the tongue and wait 10 minutes
• B. Take up to five tablets during an angina episode
• C. Take up to three tablets during a single angina episode
• D. Swallow the tablet with water

Correct answer: C

Rationale: The correct answer is C: 'Take up to three tablets during a single angina episode.' Nitroglycerin can be taken up to three times during an episode to relieve angina. Choice A is incorrect because the client should place the tablet under the tongue and wait for it to dissolve, not wait for 10 minutes. Choice B is incorrect because taking up to five tablets during an angina episode is excessive and not recommended. Choice D is incorrect because nitroglycerin tablets are meant to be taken sublingually, not swallowed.

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