Nursing Elites

1. A client with Alzheimer's disease is exhibiting signs of agitation and aggression. What is the nurse's priority intervention?

• A. Reassure the client and provide emotional support.
• B. Redirect the client to a quiet activity.
• C. Administer a PRN dose of lorazepam.
• D. Apply soft restraints as needed to prevent harm.

Correct answer: B

Rationale: The correct answer is to redirect the client to a quiet activity. This intervention helps reduce agitation and aggression in clients with Alzheimer's disease by providing a distraction and promoting a calming environment. Reassuring the client and providing emotional support (Choice A) can be beneficial but is not the priority in this situation. Administering a PRN dose of lorazepam (Choice C) should not be the first intervention due to the risk of adverse effects and should only be considered if other non-pharmacological interventions are ineffective. Applying restraints (Choice D) should be avoided unless absolutely necessary for the client's safety as it can lead to further distress and is not the initial priority intervention.

2. A client with a urinary tract infection (UTI) is prescribed antibiotics. What is the most important instruction for the nurse to give the client?

• A. Take the antibiotics with food
• B. Complete the full course of antibiotics
• C. Increase fluid intake to at least 2 liters per day
• D. Take over-the-counter pain relievers for discomfort

Correct answer: B

Rationale: The most crucial instruction for the nurse to give a client with a UTI who is prescribed antibiotics is to complete the full course of antibiotics. Completing the full course of antibiotics is essential to ensure that the infection is fully treated and to prevent the development of antibiotic resistance. While taking antibiotics with food, increasing fluid intake, and managing discomfort with pain relievers are important aspects of UTI management, completing the prescribed course of antibiotics is the top priority to achieve the best treatment outcomes and prevent recurrence of the infection.

3. A client with osteoarthritis is prescribed acetaminophen. What is the most important teaching the nurse should provide?

• A. Take the medication with food to improve absorption.
• B. Avoid taking other pain medications to prevent liver damage.
• C. Take acetaminophen on an empty stomach to prevent stomach upset.
• D. Monitor liver function tests regularly to detect any liver damage.

Correct answer: B

Rationale: The correct answer is B. Acetaminophen can cause liver damage if taken in excessive amounts or in combination with other medications containing acetaminophen. Clients should be advised to avoid other pain medications to prevent liver toxicity. Choice A is incorrect because acetaminophen is usually taken with or without food, not specifically on an empty stomach. Choice C is incorrect because taking acetaminophen with food can help prevent stomach upset. Choice D is incorrect because while monitoring liver function tests is important for long-term acetaminophen use, the most crucial teaching is to avoid other pain medications to prevent liver damage.

4. A 5-week-old infant who developed projectile vomiting over the last two weeks is diagnosed with hypertrophic pyloric stenosis. Which intervention should the nurse plan to implement?

• A. Instruct the mother to give the child sugar water only.
• B. Offer oral rehydration solution every 2 hours.
• C. Provide Pedialyte feedings via nasogastric tube.
• D. Maintain intravenous fluid therapy per prescription.

Correct answer: D

Rationale: The correct intervention for a 5-week-old infant diagnosed with hypertrophic pyloric stenosis and experiencing projectile vomiting is to maintain intravenous fluid therapy. Intravenous fluids are crucial for rehydrating an infant suffering from dehydration due to rapid fluid loss from vomiting. Instructing the mother to provide sugar water only (choice A) is inappropriate and insufficient for rehydration. Offering oral rehydration solution every 2 hours (choice B) may not be effective if the infant continues to vomit. Providing Pedialyte feedings via nasogastric tube (choice C) may also not be as effective as intravenous fluid therapy in rapidly replenishing fluids and stabilizing the child's condition.

5. A client with chronic heart failure is admitted with worsening dyspnea. What is the nurse's priority action?

• A. Administer oxygen at 2 liters per nasal cannula.
• B. Administer a diuretic as prescribed.
• C. Assess the client's lung sounds.
• D. Reposition the client to relieve dyspnea.

Correct answer: A

Rationale: In a client with chronic heart failure experiencing worsening dyspnea, the priority action for the nurse is to administer oxygen at 2 liters per nasal cannula. This helps improve oxygenation and alleviate respiratory distress. Administering a diuretic (Choice B) may be necessary but addressing oxygenation comes first. While assessing lung sounds (Choice C) is important, it is not the immediate priority when the client is in respiratory distress. Repositioning the client (Choice D) may help with comfort but does not address the underlying issue of inadequate oxygenation.

Similar Questions