Nursing Elites

1. A client admitted to the intensive care unit with syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which intervention should the nurse implement first?

• A. Patch one eye.
• B. Reorient often.
• C. Range of motion.
• D. Evaluate swallow

Correct answer: B

Rationale: Frequent reorientation is crucial for clients with neurological impairments from osmotic demyelination to prevent confusion and assist with orientation. It helps maintain a proper sense of time, place, and person, reducing disorientation. Patching one eye (Choice A) is not a priority intervention for osmotic demyelination and does not address the immediate need for reorientation. Range of motion exercises (Choice C) may be important for overall care, but reorientation takes precedence due to its impact on neurological functioning. Evaluating swallow (Choice D) is not the primary intervention needed for osmotic demyelination; it is essential but not the first priority.

2. In preparing to administer a scheduled dose of intravenous furosemide (Lasix) to a client with heart failure, the nurse notes that the client’s B-Type Naturetic peptide (BNP) is elevated. What action should the nurse take?

• A. Measure the client’s oxygen saturation before taking further action
• B. Administer a PRN dose of nitroglycerin (Nitrostat)
• C. Administer the dose of furosemide as scheduled
• D. Hold the dose of furosemide until contacting the healthcare provider

Correct answer: D

Rationale: Elevated BNP levels in a client with heart failure may indicate worsening heart failure. Therefore, the correct action for the nurse to take when encountering an elevated BNP before administering furosemide is to hold the dose and contact the healthcare provider for further guidance. This precaution is necessary to ensure the client's safety and prevent potential complications. Options A and B are incorrect as they do not address the issue of the elevated BNP, which is crucial in this situation. Option C is also incorrect because administering furosemide without consulting the healthcare provider could be harmful if the client's condition is deteriorating.

3. Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room?

• A. Ensure that the knot can be quickly released.
• B. Tie the knot with a double turn or square knot.
• C. Move the ties so the restraints are secured to the side rails.
• D. Ensure that the restraints are snug against the client's wrist.

Correct answer: A

Rationale: The correct action for the nurse to take before leaving the room is to ensure that the knot can be quickly released. Using a half bow knot to attach the client's wrist restraints allows for quick release in case of an emergency. This is crucial for ensuring the safety of the client and complying with restraint policies. Tying the knot with a double turn or square knot (Choice B) would make it difficult to release quickly when needed. Moving the ties so the restraints are secured to the side rails (Choice C) does not address the immediate need for a quick release. Ensuring that the restraints are snug against the client's wrist (Choice D) may not be appropriate if the restraints need to be quickly removed for the client's safety.

4. A client with rheumatoid arthritis reports a new onset of increasing fatigue. What intervention should the nurse implement first?

• A. Assist the client in conserving energy during daily activities
• B. Explain to the client that this could be a side effect of the medication
• C. Assess the client for pallor
• D. Encourage the client to maintain a balanced diet and hydration

Correct answer: C

Rationale: The correct first intervention for a client with rheumatoid arthritis reporting increasing fatigue is to assess the client for pallor. Fatigue can be a sign of anemia or other complications; assessing for pallor can help determine if anemia is the cause. Option A is incorrect as it does not address the underlying cause of fatigue. Option B assumes the cause without further assessment. Option D is important for overall health but assessing for pallor takes precedence to identify immediate issues related to fatigue.

5. The nurse is providing care for a client with chronic obstructive pulmonary disease (COPD). Which intervention is most appropriate to include in the care plan?

• A. Instruct the client to use pursed-lip breathing
• B. Recommend a high-fat, low-carbohydrate diet
• C. Limit physical activity to prevent shortness of breath
• D. Encourage the client to drink large amounts of fluids

Correct answer: A

Rationale: The correct answer is A: Instruct the client to use pursed-lip breathing. Pursed-lip breathing helps improve ventilation and reduce shortness of breath in COPD clients. This technique involves inhaling slowly through the nose and exhaling through pursed lips. Choice B is incorrect because a high-fat, low-carbohydrate diet is not recommended for individuals with COPD as it can lead to weight gain and worsen respiratory function. Choice C is incorrect as limiting physical activity can lead to deconditioning and worsen COPD symptoms. Regular, moderate exercise is beneficial for individuals with COPD. Choice D is incorrect as excessive fluid intake can strain the heart in COPD clients. It is important to maintain adequate but not excessive fluid intake to prevent dehydration and maintain optimal lung function.

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