Nursing Elites

1. A nurse in a provider’s office is caring for a client who states, “I always have trouble sleeping.” Which of the following actions should the nurse take first?

• A. Teach the client stress reduction techniques
• B. Recommend that the client avoid caffeine intake in the evening
• C. Identify the client’s typical bedtime routine
• D. Encourage the client to exercise regularly during daytime hours

Correct answer: C

Rationale: The correct action for the nurse to take first is to identify the client’s typical bedtime routine. Understanding the client’s sleep habits, environment, and bedtime rituals can provide valuable insight into potential factors contributing to their sleep troubles. Teaching stress reduction techniques (choice A) may be beneficial but should come after understanding the client's routine. Recommending avoiding caffeine intake in the evening (choice B) and encouraging regular daytime exercise (choice D) are important interventions, but identifying the bedtime routine takes precedence as it directly addresses the client's immediate concern.

2. A client with a history of asthma presents to the emergency department with difficulty breathing and wheezing. Which of the following is the priority nursing action?

• A. Administer a bronchodilator
• B. Obtain a peak flow reading
• C. Provide supplemental oxygen
• D. Assess the client's respiratory rate

Correct answer: A

Rationale: In a client with a history of asthma experiencing difficulty breathing and wheezing, the priority nursing action is to administer a bronchodilator. This intervention helps relieve bronchospasm and improve the client's breathing. Obtaining a peak flow reading can provide additional information but is not the immediate priority in this situation. Providing supplemental oxygen may be needed but addressing the bronchospasm with a bronchodilator takes precedence. Assessing the client's respiratory rate is important but not as urgent as administering a bronchodilator to address the breathing difficulty.

3. A client with a history of hypertension is prescribed a low-sodium diet. Which food should the LPN/LVN recommend the client avoid?

• A. Fresh fruits
• B. Grilled chicken
• C. Whole grain bread
• D. Canned soup

Correct answer: D

Rationale: The correct answer is D, canned soup. Canned soups are often high in sodium content, which can be harmful to individuals with hypertension following a low-sodium diet. Fresh fruits, grilled chicken, and whole grain bread are generally healthier options with lower sodium content and can be included in a low-sodium diet. Fresh fruits provide essential vitamins and minerals, grilled chicken is a lean protein source, and whole grain bread offers fiber and nutrients without excessive sodium levels. Avoiding canned soup aligns with the goal of reducing sodium intake to manage hypertension.

4. Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the LPN that it is much bigger than he expected. What is the best response by the nurse?

• A. Reassure the client that he will become accustomed to the stoma's appearance in time.
• B. Instruct the client that the stoma will become smaller when the initial swelling diminishes.
• C. Offer to contact a member of the local ostomy support group to help him with his concerns.
• D. Encourage the client to handle the stoma equipment to gain confidence with the procedure.

Correct answer: B

Rationale: The correct response is to instruct the client that the stoma will become smaller when the initial swelling diminishes. This explanation helps reassure the client about the temporary appearance of the stoma. Choice A is incorrect because simply reassuring the client that he will become accustomed to the stoma's appearance does not address the immediate concern about the stoma size. Choice C is incorrect because offering to contact a support group does not directly address the client's current distress about the stoma size. Choice D is incorrect because encouraging the client to handle stoma equipment does not directly address the client's concern about the stoma size and may not be appropriate at this time.

5. After repositioning a client who reports shortness of breath, which of the following actions should the nurse take next?

• A. Observe the rate, depth, and character of the client's respirations.
• B. Take the client’s blood pressure.
• C. Assess the client's pulse.
• D. Offer supplemental oxygen.

Correct answer: A

Rationale: Observing the rate, depth, and character of the client's respirations is crucial after repositioning a client experiencing shortness of breath. This action provides immediate information about the client's respiratory status. Checking blood pressure (Choice B) is not the priority in this situation, as assessing respirations is more urgent. Assessing the pulse (Choice C) is also important but does not provide direct information about the client's respiratory status. Offering supplemental oxygen (Choice D) may be necessary based on the assessment of respirations, but it should not be the first action taken without assessing the client's breathing pattern.

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