Nursing Elites

1. A client is having difficulty breathing while laying in bed with a nasal cannula delivering oxygen. Which of the following interventions should the nurse take first?

• A. Suction the client's airway
• B. Administer a bronchodilator
• C. Increase the humidity in the client's room
• D. Assist the client to an upright position

Correct answer: D

Rationale: The correct answer is to assist the client to an upright position. When a client is having difficulty breathing, promoting optimal oxygenation is essential. Elevating the head of the bed improves ventilation and lung expansion by reducing pressure on the diaphragm. This position allows the lungs to expand fully, enhancing oxygen exchange. Suctioning the airway may be necessary if there are secretions causing obstruction, but it is not the first intervention in this scenario. Administering a bronchodilator is appropriate for bronchoconstriction but does not address the immediate need for better ventilation. Increasing humidity can be beneficial in certain respiratory conditions, but it is not the initial priority when a client is struggling to breathe.

2. When providing hygiene for an older-adult patient, why does the nurse closely assess the skin?

• A. Outer skin layer becomes less resilient.
• B. Less frequent bathing may be required.
• C. Skin becomes more subject to bruising.
• D. Sweat glands become less active.

Correct answer: B

Rationale: The correct answer is B: 'Less frequent bathing may be required.' In older adults, daily bathing or using hot water and harsh soap can lead to excessively dry skin. Therefore, the nurse closely assesses the skin to determine if less frequent bathing is necessary to prevent skin dryness and maintain skin integrity. Choice A is incorrect because the outer skin layer does not become less resilient with age. Choice C is incorrect as aging skin is actually more prone to bruising due to thinning of the skin. Choice D is incorrect because sweat gland activity generally decreases with age, leading to reduced skin moisture rather than increased activity.

3. A client on a telemetry unit is being cared for by a nurse after a myocardial infarction. The client expresses, 'All this equipment is making me nervous.' Which of the following responses should the nurse make?

• A. 'All of this equipment can be frightening.'
• B. 'The equipment is necessary to monitor your condition.'
• C. 'You should try to ignore the equipment.'
• D. 'Try to relax; the equipment is not harmful.'

Correct answer: A

Rationale: Choice A is the most appropriate response as it acknowledges the client's feelings, showing empathy and understanding. It validates the client's experience, which can help reduce anxiety and build rapport. Choice B provides information but may not address the client's emotional needs. Choice C dismisses the client's concerns and does not offer support. Choice D minimizes the client's feelings and may not effectively address their anxiety.

4. A healthcare professional is preparing to administer an opioid medication to a client for pain management. Which of the following actions should the healthcare professional take?

• A. Administer the medication as prescribed without any additional monitoring.
• B. Monitor the client for respiratory depression.
• C. Administer the medication only when the client requests it.
• D. Ask another healthcare professional to verify the medication before administration.

Correct answer: B

Rationale: When administering opioid medications, it is crucial to monitor the client for respiratory depression, which is a potential side effect of opioids. Monitoring for respiratory depression is a critical safety measure to ensure the client's well-being during opioid therapy. Option A is incorrect because additional monitoring, especially for respiratory depression, is necessary when giving opioids to prevent adverse effects. Option C is incorrect as administering the medication only upon client request may compromise effective pain management and adherence to the prescribed regimen. Option D is incorrect as medication verification by another healthcare professional is essential for safety but not directly related to monitoring the client for respiratory depression after opioid administration.

5. If a security officer is reviewing actions to take in the event of a bomb threat by phone to a group of nurses, which statement by a nurse indicates understanding?

• A. “I will get the caller off the phone as soon as possible so I can alert the staff.”
• B. “I will begin evacuating clients using the elevators.”
• C. “I will not ask any questions and just let the caller talk.”
• D. “I will listen for background noises.”

Correct answer: D

Rationale: The correct answer is D: “I will listen for background noises.” Listening for background noises can provide useful information about the bomb’s location, helping security to assess the situation more effectively. Choice A is incorrect because disconnecting the call abruptly may prevent gathering important details. Choice B is incorrect as using elevators during a bomb threat can be dangerous; it is safer to use stairs for evacuation. Choice C is incorrect because actively engaging with the caller to gather information is crucial in bomb threat situations.

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