Nursing Elites

1. A nurse is caring for a client who is in Buck's traction. Which of the following actions should the nurse take?

• A. Remove the weights
• B. Ensure the weights hang freely
• C. Increase the traction force
• D. Loosen the ropes

Correct answer: B

Rationale: The correct action the nurse should take when caring for a client in Buck's traction is to ensure the weights hang freely. This is essential to maintain proper alignment and ensure the effectiveness of Buck's traction. Removing the weights (Choice A) would be incorrect and could compromise the treatment. Increasing the traction force (Choice C) can lead to excessive pressure and potential harm to the client. Loosening the ropes (Choice D) would also be inappropriate as it can disrupt the traction's effectiveness and alignment.

2. What are the key nursing considerations for a patient with a central venous catheter?

• A. Maintain sterility during dressing changes
• B. Change the dressing weekly
• C. Monitor blood pressure and fluid balance
• D. Monitor the catheter site for infection

Correct answer: A

Rationale: The correct answer is A: Maintain sterility during dressing changes. It is crucial to maintain sterility during dressing changes for patients with central venous catheters to prevent infections. Changing the dressing weekly (Choice B) is not frequent enough to prevent infections effectively. Monitoring blood pressure and fluid balance (Choice C) is important for overall patient care but not specific to central venous catheter management. While monitoring the catheter site for infection (Choice D) is important, the key consideration is to prevent infections through proper sterile techniques during dressing changes.

3. A client with schizophrenia is experiencing auditory hallucinations. Which of the following actions should the nurse take?

• A. Encourage the client to lie down in a quiet room.
• B. Ask the client directly what they are hearing.
• C. Tell the client that the voices are not real.
• D. Provide headphones for the client to listen to music.

Correct answer: B

Rationale: The correct action for the nurse to take when caring for a client with schizophrenia experiencing auditory hallucinations is to ask the client directly what they are hearing. This approach helps the nurse gain insight into the client's experience, establish effective communication, and provide appropriate support. Encouraging the client to lie down in a quiet room (Choice A) may not address the hallucinations directly. Telling the client that the voices are not real (Choice C) can be invalidating and may lead to further distress. Providing headphones for music (Choice D) may not be effective in addressing the client's hallucinations.

4. A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?

• A. A client with pneumonia who had new onset of confusion
• B. A client with diabetes who had low blood sugar overnight
• C. A client with a leg fracture who needs pain medication
• D. A client whose urinary output was 100 mL for the past 12 hours

Correct answer: A

Rationale: The correct answer is A. New confusion in a client with pneumonia could indicate hypoxia or a worsening condition, requiring immediate attention. Option B, a client with diabetes having low blood sugar overnight, is a concerning condition but not as urgent as potential hypoxia. Option C, a client with a leg fracture needing pain medication, and option D, a client with decreased urinary output, are important but do not take precedence over addressing a potentially critical respiratory issue.

5. A client with hypertension is receiving lifestyle education from a nurse. What should be emphasized?

• A. Encourage a low-sodium diet
• B. Advise the client to avoid caffeinated drinks
• C. Recommend increasing high-protein foods
• D. Advise the client to reduce fat intake

Correct answer: B

Rationale: The correct answer is to advise the client to avoid caffeinated drinks. Caffeine can temporarily increase blood pressure, so avoiding caffeinated drinks can help manage hypertension. Encouraging a low-sodium diet (Choice A) is essential for hypertension management as excess sodium can raise blood pressure. Increasing high-protein foods (Choice C) is not a primary focus in managing hypertension. While reducing fat intake (Choice D) can be beneficial for overall health, it is not the priority in lifestyle modifications for hypertension.

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