Nursing Elites

1. A client with schizophrenia is experiencing delusions. Which of the following actions should the nurse take?

• A. Encourage the client to discuss the delusions.
• B. Tell the client that the delusions are not real.
• C. Avoid discussing the delusions with the client.
• D. Challenge the client's delusions directly.

Correct answer: B

Rationale: Telling the client that their delusions are not real is the most appropriate action as it helps ground them in reality without reinforcing the delusion. Encouraging the client to discuss the delusions (choice A) may further validate or intensify the delusions. Avoiding discussing the delusions (choice C) may lead to the client feeling isolated and unheard. Challenging the client's delusions directly (choice D) can escalate the situation and cause distress to the client.

2. A client receiving warfarin is being taught by a nurse. Which of the following client statements indicates an understanding of the teaching?

• A. I will avoid eating leafy green vegetables while taking this medication.
• B. I will need to have my INR checked regularly while taking this medication.
• C. I will take this medication at the same time each day.
• D. I will avoid taking aspirin while taking this medication.

Correct answer: D

Rationale: The correct answer is D because clients taking warfarin should avoid aspirin to reduce the risk of bleeding, as both medications can thin the blood. Choice A is incorrect because it is essential to eat a consistent amount of leafy green vegetables to maintain a steady intake of Vitamin K, which can impact warfarin's effectiveness. Choice B is incorrect although important because INR checks are necessary but do not specifically show an understanding of the teaching. Choice C is incorrect because while taking warfarin at the same time each day is beneficial for consistency, it does not directly address the interaction with aspirin.

3. A client with hypertension is receiving discharge teaching from a nurse on managing blood pressure at home. Which of the following instructions should the nurse include?

• A. Take medication at bedtime.
• B. Check blood pressure once a week.
• C. Use a blood pressure cuff that fits snugly around the arm.
• D. Stop taking medication once blood pressure is within the normal range.

Correct answer: C

Rationale: The correct answer is C: 'Use a blood pressure cuff that fits snugly around the arm.' Using a properly fitting cuff is essential for accurate blood pressure measurements. Choice A is incorrect because the timing of medication administration should be individualized and not specified in the question. Choice B is incorrect as checking blood pressure once a week may not provide sufficient monitoring for a client with hypertension. Choice D is incorrect because stopping medication abruptly once blood pressure is normal can lead to rebound hypertension and complications.

4. A healthcare professional is caring for a client who has an arteriovenous fistula. Which of the following findings should the healthcare professional report?

• A. Thrill upon palpation.
• B. Absence of a bruit.
• C. Distended blood vessels.
• D. Swishing sound upon auscultation.

Correct answer: B

Rationale: The correct answer is B: Absence of a bruit. In a client with an arteriovenous fistula, the presence of a bruit (a humming sound) is an expected finding due to the high-pressure flow of blood through the fistula. Therefore, the absence of a bruit suggests a complication, such as thrombosis or stenosis, which should be reported for further evaluation and management. Choices A, C, and D are incorrect because a thrill upon palpation, distended blood vessels, and a swishing sound upon auscultation are expected findings in a client with an arteriovenous fistula and do not necessarily indicate a complication.

5. What is the best nursing action for a patient experiencing shortness of breath?

• A. Administer oxygen
• B. Administer bronchodilators
• C. Reposition the patient
• D. Provide IV fluids

Correct answer: A

Rationale: Administering oxygen is the best nursing action for a patient experiencing shortness of breath as it helps alleviate the symptoms and improve oxygenation. Providing oxygen addresses the primary issue of inadequate oxygen levels in the body, which can be a life-threatening situation. Administering bronchodilators (choice B) may be appropriate for specific respiratory conditions like asthma but is not the initial intervention for all causes of shortness of breath. Repositioning the patient (choice C) can sometimes help improve breathing, but in a patient experiencing significant shortness of breath, immediate oxygen therapy is crucial. Providing IV fluids (choice D) is not indicated as the first-line intervention for shortness of breath unless there is a specific underlying cause such as dehydration.

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