Nursing Elites

1. A client who is intubated and has an intra-aortic balloon pump is restless and agitated. What action should the nurse perform first for comfort?

• A. Allow family members to remain at the bedside.
• B. Ask the family if the client would like a fan in the room.
• C. Keep the television tuned to the client's favorite channel.
• D. Speak loudly to the client in case of hearing problems.

Correct answer: A

Rationale: Allowing the family to remain at the bedside can help calm the client with familiar voices and presence, potentially reducing restlessness and agitation. Introducing a fan may not be the priority as it can spread germs through air movement. Keeping the television on all the time may not promote rest and recovery. Speaking loudly is not advisable as it may further agitate the client. Therefore, the initial action of allowing family members to stay is most likely to provide comfort and reassurance to the client.

2. A client with asthma is being taught about peak flow meter use. Which statement by the client indicates understanding of the teaching?

• A. I will use my peak flow meter every morning.
• B. I will use my peak flow meter when I feel short of breath.
• C. I will use my peak flow meter before using my inhaler.
• D. I will use my peak flow meter after using my inhaler.

Correct answer: A

Rationale: The correct answer is A. Using the peak flow meter every morning is crucial for monitoring asthma control and making timely treatment adjustments. While using the meter when feeling short of breath or before using an inhaler can also be beneficial, the daily morning routine helps in consistent management of asthma symptoms.

3. When interviewing a client recently diagnosed with lung cancer and having a 60-pack-year smoking history, what is the most important action for the nurse to take?

• A. Educate the client about the importance of quitting smoking to halt cancer progression.
• B. Encourage the client to disclose both tobacco and marijuana use openly.
• C. Maintain a nonjudgmental attitude to promote honest communication with the client.
• D. Provide realistic information about cancer treatment and prognosis without giving false hope.

Correct answer: C

Rationale: Maintaining a nonjudgmental attitude during the interview is crucial to create a safe environment where the client feels comfortable and open about disclosing their smoking history and other relevant information. This approach helps establish trust and facilitates an honest conversation which is essential for providing appropriate care and support to the client.

4. A client with dyspnea and difficulty climbing stairs is classified as having class III dyspnea. Which intervention should the nurse include in the client's plan of care?

• A. Assistance with activities of daily living.
• B. Daily physical therapy activities.
• C. Oxygen therapy at 2 liters per nasal cannula.
• D. Complete bedrest with frequent repositioning.

Correct answer: A

Rationale: Class III dyspnea indicates significant limitations in activity due to shortness of breath. Clients with this level of dyspnea should be encouraged to participate in activities within their tolerance levels. Providing assistance with activities of daily living helps conserve energy for essential tasks while promoting independence. Oxygen therapy is only necessary if hypoxia is present, and complete bedrest is generally not recommended for clients with dyspnea unless specifically indicated.

5. A client with end-stage heart failure who is awaiting a transplant appears depressed and states, 'I know a transplant is my last chance, but I don't want to become a vegetable.' How should the nurse respond?

• A. Would you like information about advance directives?
• B. I will arrange for a psychiatrist to speak with you.
• C. Do you want to come off the transplant list?
• D. Would you like to speak with a priest or chaplain?

Correct answer: A

Rationale: The client is expressing a fear of negative outcomes related to the transplant. By offering information about advance directives, the nurse allows the client to discuss concerns and preferences for end-of-life care. This response shows empathy, acknowledges the client's autonomy, and addresses the client's fears while providing support and information.

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