Nursing Elites

1. A client who experienced an acute myocardial infarction expresses concern about fatigue. What is the best strategy to promote self-care?

• A. Ask family members to assist with all self-care tasks
• B. Encourage the client to gradually resume self-care tasks with frequent rest periods
• C. Instruct the client to remain in bed until fully rested
• D. Assign assistive personnel to complete self-care tasks for the client

Correct answer: B

Rationale: Encouraging the client to gradually resume self-care tasks with frequent rest periods is the best strategy to promote self-care for a client who experienced an acute myocardial infarction and is experiencing fatigue. This approach helps the client regain independence while managing fatigue. Asking family members to assist with all self-care tasks (Choice A) may hinder the client's independence. Instructing the client to remain in bed until fully rested (Choice C) may lead to deconditioning and dependency. Assigning assistive personnel to complete self-care tasks for the client (Choice D) does not empower the client to regain independence or actively participate in self-care.

2. What is the most appropriate intervention for a client with phlebitis at the IV site?

• A. Apply a warm compress to the site
• B. Discontinue the IV and notify the provider
• C. Increase the IV flow rate to prevent dehydration
• D. Monitor the site for signs of infection

Correct answer: B

Rationale: The most appropriate intervention for a client with phlebitis at the IV site is to discontinue the IV and notify the provider. Phlebitis is inflammation of the vein, and continuing the IV can lead to complications such as infection or thrombosis. Applying a warm compress may provide symptomatic relief but does not address the root cause. Increasing the IV flow rate is not indicated and may worsen the inflammation. Monitoring for signs of infection is important, but the priority is to remove the source of inflammation by discontinuing the IV.

3. Which of the following is a realistic short-term goal to be accomplished in 2 to 3 days for a client with delirium?

• A. Explain the experience of having delirium
• B. Resume a normal sleep-wake cycle
• C. Regain orientation to time and place
• D. Establish normal bowel and bladder function

Correct answer: C

Rationale: Regaining orientation to time and place is a realistic short-term goal for clients with delirium. It helps the individual become aware of their surroundings and current situation, aiding in reducing confusion and disorientation. Choice A is incorrect because the goal is focused on the client's understanding, not on explaining the experience of delirium. Choice B, resuming a normal sleep-wake cycle, may take longer than 2 to 3 days to achieve and is not directly related to regaining orientation. Choice D, establishing normal bowel and bladder function, is important but may not be a short-term goal specifically related to delirium.

4. What is the nurse's priority when caring for a client with a tracheostomy who is showing signs of respiratory distress?

• A. Administer a bronchodilator
• B. Suction the tracheostomy
• C. Notify the physician immediately
• D. Increase the oxygen flow rate

Correct answer: B

Rationale: The correct answer is to suction the tracheostomy. When a client with a tracheostomy is experiencing respiratory distress, the priority intervention is to clear the airway by suctioning the tracheostomy to remove secretions that may be obstructing the air passage. Administering a bronchodilator (Choice A) may be considered if bronchospasm is present, but the immediate focus should be on clearing the airway. Notifying the physician (Choice C) is important but should not delay the immediate intervention of suctioning. Increasing the oxygen flow rate (Choice D) may provide temporary relief, but addressing the root cause of the distress by suctioning is the priority.

5. A nurse is planning care for a preschool-age child who is in the acute phase of Kawasaki disease. Which of the following interventions should the nurse include in the plan of care?

• A. Administer scheduled doses of acetaminophen every 6 hr.
• B. Monitor the child's cardiac status.
• C. Administer antibiotics via intermittent IV bolus for 24 hr.
• D. Provide stimulation with children of the same age in the playroom.

Correct answer: B

Rationale: Monitoring cardiac status is crucial during the acute phase of Kawasaki disease because of the potential for coronary artery complications. Acetaminophen may be used for fever management but is not the priority intervention. Antibiotics are not indicated as Kawasaki disease is not caused by a bacterial infection. Providing stimulation in the playroom is important for the child's emotional well-being but does not address the immediate physiological concern of cardiac monitoring.

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