Nursing Elites

1. When caring for a client experiencing delirium, which of the following is essential?

• A. Controlling behavioral symptoms with low-dose psychotropics
• B. Identifying the underlying causative condition or illness
• C. Manipulating the environment to increase orientation
• D. Decreasing or discontinuing all previously prescribed medications

Correct answer: B

Rationale: When caring for a client experiencing delirium, it is essential to identify the underlying causative condition or illness. Delirium can be caused by various factors such as infections, medication side effects, dehydration, or underlying health conditions. By identifying the root cause, appropriate treatment can be provided. Controlling behavioral symptoms with low-dose psychotropics (Choice A) may be considered in some cases but is not the primary essential step. Manipulating the environment to increase orientation (Choice C) can help manage symptoms but does not address the underlying cause. Decreasing or discontinuing all previously prescribed medications (Choice D) should only be done under medical supervision, as some medications may be necessary for the client's well-being.

2. A client with a chest tube is post-op. What is the priority nursing action?

• A. Clamp the chest tube every 2 hours
• B. Check for air leaks and proper functioning of the chest tube
• C. Encourage deep breathing and coughing every 2 hours
• D. Encourage frequent coughing to clear secretions

Correct answer: B

Rationale: The correct answer is to check for air leaks and ensure the proper functioning of the chest tube. This action is crucial post-op to prevent complications such as pneumothorax or hemothorax. Clamping the chest tube every 2 hours (Choice A) is incorrect as it can lead to a buildup of pressure within the chest, risking complications. Encouraging deep breathing and coughing every 2 hours (Choice C) is important for respiratory hygiene but not the priority over ensuring the chest tube's proper function. Encouraging frequent coughing to clear secretions (Choice D) is not the priority when assessing a chest tube post-op; ensuring the chest tube's integrity and function take precedence.

3. A client has a prescription for ciprofloxacin. Which of the following instructions should the nurse include?

• A. Take the medication with an antacid if you experience gastrointestinal upset.
• B. You should limit your caffeine intake while taking this medication.
• C. This medication may cause your urine to turn dark brown.
• D. You should avoid taking this medication with dairy products.

Correct answer: D

Rationale: The correct answer is D: 'You should avoid taking this medication with dairy products.' Ciprofloxacin should not be taken with dairy products as they can interfere with the absorption of the medication. Choice A is incorrect because ciprofloxacin should not be taken with antacids containing aluminum or magnesium. Choice B is incorrect as there is no specific limitation on caffeine intake associated with ciprofloxacin. Choice C is incorrect as ciprofloxacin does not typically cause urine to turn dark brown.

4. Which of the following situations can be identified as an ethical dilemma?

• A. A nurse demonstrates signs of chemical impairment
• B. A family has conflicting feelings about tube feeding for their terminally ill father
• C. A nurse overhears a colleague threatening to restrain a patient if they do not stay in bed
• D. A client with terminal cancer hesitates to name their spouse as power of attorney

Correct answer: B

Rationale: The correct answer is B. Ethical dilemmas involve conflicting values or feelings. In this situation, the family is conflicted about tube feeding for their terminally ill father, which presents a moral and ethical challenge. Choices A, C, and D do not represent ethical dilemmas. Choice A involves a nurse's impairment, which is a different issue. Choice C involves a nurse's observation of a colleague's threat, which is a patient safety concern. Choice D involves a client's hesitation in naming a spouse as power of attorney, which is a legal and decision-making issue, not necessarily an ethical dilemma.

5. A nurse is assessing a client who has dehydration. Which of the following findings should the nurse expect?

• A. Bradycardia.
• B. Elevated blood pressure.
• C. Furrows in the tongue.
• D. Polyuria.

Correct answer: C

Rationale: The correct answer is C: 'Furrows in the tongue.' Dehydration commonly presents with furrows in the tongue due to decreased oral moisture. This physical finding indicates dehydration as the tongue loses moisture and becomes dry. Choice A, 'Bradycardia,' is not typically associated with dehydration; instead, tachycardia may be present as a compensatory mechanism. Elevated blood pressure, as mentioned in choice B, is not a typical finding in dehydration; in fact, dehydration often leads to a decrease in blood pressure. Polyuria, as in choice D, is more commonly associated with conditions like diabetes mellitus or diabetes insipidus, rather than dehydration.

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