Nursing Elites

1. A nurse is caring for a client who is requesting to leave the facility against medical advice (AMA). The client states, 'I am ready to go immediately.' Which of the following actions should the nurse take first?

• A. Teach the client about the potential health risks of leaving early
• B. Ask the client to sign a document stating they are leaving AMA
• C. Document the client's statement in direct quotes in the medical record
• D. Complete an incident report detailing the client scenario

Correct answer: A

Rationale: The correct action for the nurse to take first is to educate the client about the potential health risks of leaving against medical advice (AMA). By providing this information, the nurse can help the client make an informed decision regarding their healthcare. Choice B, asking the client to sign a document, can be done after the client has been informed about the risks. Choice C, documenting the client's statement, is important but should not take precedence over educating the client. Choice D, completing an incident report, is not the priority when a client is requesting to leave AMA.

2. A healthcare professional is preparing to admit a client to the PACU who received a competitive neuromuscular blocking agent. Which of the following items should the healthcare professional place at the client's bedside?

• A. Defibrillator machine
• B. Chest tube equipment
• C. Central venous catheter tray
• D. Bag-valve-mask device

Correct answer: D

Rationale: Corrected Rationale: A bag-valve-mask device is necessary in case of respiratory complications that may arise due to the effects of the neuromuscular blocking agent. The competitive nature of the agent can lead to muscle weakness, including respiratory muscles, necessitating immediate respiratory support. Placing a defibrillator machine, chest tube equipment, or central venous catheter tray at the client's bedside would not be the priority in this situation. While these items may be important in specific scenarios, ensuring the availability of a bag-valve-mask device is crucial to address potential airway and breathing issues promptly.

3. What is the primary purpose of turning and repositioning an immobile patient every 2 hours?

• A. To improve circulation and relieve pressure.
• B. To prevent contractures and muscle atrophy.
• C. To prevent skin breakdown and pressure ulcers.
• D. To improve respiratory function and prevent pneumonia.

Correct answer: C

Rationale: The primary purpose of turning and repositioning an immobile patient every 2 hours is to prevent skin breakdown and pressure ulcers. Prolonged immobility can lead to pressure ulcers, making this a crucial nursing intervention. Choice A is incorrect because while turning can help improve circulation and relieve pressure, the primary purpose is to prevent skin breakdown. Choice B is incorrect as preventing contractures and muscle atrophy is important but not the primary purpose of turning. Choice D is incorrect as improving respiratory function and preventing pneumonia are not directly related to turning and repositioning for skin integrity.

4. A case manager at an assisted living facility is reviewing the use of complementary health practices by several clients. Which of the following actions should the case manager plan to take?

• A. Plan to report a client's use of echinacea to the provider as a contraindication to aspirin therapy
• B. Plan to schedule time for a new client to continue tai chi practice as a stress reduction technique
• C. Tell a client that yoga has not been proven effective to reduce manifestations of menopause
• D. Tell a client who drinks cranberry juice daily that it can help treat existing urinary tract infections

Correct answer: B

Rationale: The correct answer is B. Tai chi is a recognized complementary health practice for stress reduction. Scheduling time for a new client to continue tai chi practice aligns with supporting holistic care. Choice A is incorrect because reporting a client's use of echinacea as a contraindication to aspirin therapy is not necessary without further context or evidence of interactions. Choice C is wrong because yoga can indeed be effective in reducing manifestations of menopause. Choice D is also incorrect because while cranberry juice is known to help prevent urinary tract infections, it is not typically used to treat existing infections.

5. What is the most appropriate intervention for a client experiencing acute alcohol withdrawal?

• A. Encourage physical activity to reduce withdrawal symptoms
• B. Administer diazepam to prevent seizures
• C. Monitor for signs of dehydration
• D. Encourage the client to verbalize their feelings

Correct answer: B

Rationale: The most appropriate intervention for a client experiencing acute alcohol withdrawal is to administer diazepam. Diazepam is a benzodiazepine commonly used to prevent seizures and manage the symptoms of alcohol withdrawal. Encouraging physical activity may not be safe during acute withdrawal as the client may be at risk for seizures and other complications. Monitoring for signs of dehydration is important but not the most immediate intervention needed in acute alcohol withdrawal. While encouraging the client to verbalize their feelings is beneficial for therapeutic communication, it is not the priority intervention when managing acute alcohol withdrawal.

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