Nursing Elites

1. A client with a history of depression is experiencing a situational crisis. Which of the following actions should the nurse take first?

• A. Confirm the client's perception of the event.
• B. Notify the client's support system.
• C. Help the client identify personal strengths.
• D. Teach the client relaxation techniques.

Correct answer: A

Rationale: The correct answer is to confirm the client's perception of the event. In crisis intervention, understanding the client's perspective is crucial as it helps the nurse assess the situation accurately and provide tailored support. This step can also help build rapport and trust with the client. Option B, notifying the client's support system, may be important but should come after assessing the client's perception. Option C, helping the client identify personal strengths, and option D, teaching relaxation techniques, are valuable interventions but should follow the initial step of confirming the client's perception.

2. What is the priority nursing intervention for a patient experiencing an acute asthma attack?

• A. Administer bronchodilators
• B. Monitor oxygen saturation
• C. Provide supplemental oxygen
• D. Start IV fluids

Correct answer: A

Rationale: The correct answer is to administer bronchodilators. In an acute asthma attack, the priority is to open the airways and improve airflow. Bronchodilators like albuterol are crucial in providing immediate relief to the patient. Monitoring oxygen saturation (choice B) is important but administering bronchodilators takes precedence in managing the acute attack. Providing supplemental oxygen (choice C) may be necessary but addressing the airway obstruction with bronchodilators is the priority. Starting IV fluids (choice D) is not the priority in an acute asthma attack unless specifically indicated for other reasons such as dehydration.

3. What is the best intervention for a patient experiencing respiratory distress?

• A. Administer oxygen
• B. Administer bronchodilators
• C. Administer IV fluids
• D. Provide chest physiotherapy

Correct answer: A

Rationale: Administering oxygen is the best intervention for a patient experiencing respiratory distress because it helps improve oxygenation and alleviate respiratory distress. Oxygen therapy is crucial in ensuring that the patient receives an adequate supply of oxygen to meet the body's demands. Administering bronchodilators (Choice B) may be beneficial in specific respiratory conditions like asthma or COPD but may not be the primary intervention in all cases of respiratory distress. Administering IV fluids (Choice C) may be necessary in cases of dehydration or shock but would not directly address respiratory distress. Providing chest physiotherapy (Choice D) can help mobilize secretions in conditions like cystic fibrosis but is not the first-line intervention for respiratory distress.

4. A client who is postpartum requests information about contraception. Which of the following instructions should the nurse include?

• A. The lactation amenorrhea method is effective for the first year postpartum.
• B. You should not use the diaphragm used before your pregnancy.
• C. Apply the transdermal birth control patch on your upper arm.
• D. Avoid using vaginal spermicides while breastfeeding.

Correct answer: D

Rationale: The correct answer is to advise the client to avoid using vaginal spermicides while breastfeeding. This instruction is important as spermicides can potentially affect the milk supply and cause irritation. Choice A is incorrect because the effectiveness of the lactation amenorrhea method diminishes after the first six months postpartum. Choice B is incorrect as using the diaphragm used before pregnancy may not fit properly due to changes in the body postpartum. Choice C is incorrect as the transdermal birth control patch is typically applied to the abdomen, buttocks, or upper torso, not specifically the upper arm.

5. What is the initial action a healthcare provider should take when a patient presents with chest pain?

• A. Administer aspirin
• B. Give oxygen therapy
• C. Obtain ECG
• D. Prepare for surgery

Correct answer: C

Rationale: The correct initial action when a patient presents with chest pain is to obtain an ECG. This helps assess the heart's electrical activity and determine the cause of chest pain. Administering aspirin or oxygen therapy may be necessary later based on the ECG findings, but obtaining an ECG is the priority to evaluate the cardiac status. Surgery preparation is not the initial action for chest pain and should only be considered after a thorough assessment.

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