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. A client is prescribed albuterol. Which of the following instructions should the nurse include?

• A. Take this medication before meals.
• B. You might experience tremors while taking this medication.
• C. Limit your caffeine intake while taking this medication.
• D. Take this medication at bedtime.

Correct answer: B

Rationale: The correct answer is B. Albuterol can cause tremors as a common side effect. Instructing the client about this potential side effect is crucial for their awareness and preparedness. Choices A, C, and D are incorrect because taking albuterol before meals, limiting caffeine intake, or taking it at bedtime are not specific instructions related to managing the side effects of albuterol like tremors.

3. A patient is 1 day postoperative following a total knee arthroplasty. Which of the following actions should the nurse take?

• A. Administer aspirin for pain management.
• B. Keep the affected leg in a dependent position.
• C. Flex the affected knee for 2 to 3 minutes every hour.
• D. Apply ice packs to the affected knee.

Correct answer: D

Rationale: The correct action for a client 1 day postoperative following a total knee arthroplasty is to apply ice packs to the affected knee. Ice packs help reduce swelling and pain in such clients. Administering aspirin is contraindicated due to the risk of bleeding postoperatively. Keeping the affected leg in a dependent position can impair circulation and increase the risk of complications. Flexing the affected knee for extended periods can strain the surgical site and hinder the healing process.

4. A nurse is assessing a client who has acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse expect?

• A. Barrel-shaped chest
• B. Bradycardia
• C. Increased respiratory rate
• D. Tracheal deviation

Correct answer: C

Rationale: Corrected Rationale: An increased respiratory rate is a common finding in clients with ARDS as the body attempts to compensate for impaired gas exchange. Barrel-shaped chest (Choice A) is associated with conditions like COPD, not ARDS. Bradycardia (Choice B) is unlikely in ARDS due to the body's compensatory mechanisms to improve oxygenation. Tracheal deviation (Choice D) is not typically seen in ARDS and is more suggestive of other respiratory conditions.

5. A client who has a new prescription for levothyroxine is receiving teaching from a nurse. Which statement by the client indicates an understanding of the teaching?

• A. I will need to take this medication for 3 months.
• B. I will take this medication with an antacid.
• C. I will avoid foods that contain iodine.
• D. I will take this medication in the morning before breakfast.

Correct answer: D

Rationale: The correct answer is D: "I will take this medication in the morning before breakfast." Levothyroxine should be taken in the morning before breakfast to improve absorption and effectiveness. Choice A is incorrect because the duration of levothyroxine therapy is usually long-term and not limited to 3 months. Choice B is incorrect because levothyroxine should not be taken with antacids as they may decrease its absorption. Choice C is incorrect because there is no need to avoid foods that contain iodine while taking levothyroxine.

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