Nursing Elites

1. A client requires seclusion to prevent harm to others on the unit. What action should the nurse take?

• A. Offer fluids every 2 hours.
• B. Document the client's behavior prior to being placed in seclusion.
• C. Discuss the client's inappropriate behavior prior to seclusion.
• D. Assess the client's behavior every hour.

Correct answer: B

Rationale: The correct answer is to document the client's behavior prior to being placed in seclusion. Documenting the behavior is crucial as it ensures that the decision to use seclusion is based on appropriate justifications and helps in monitoring the client's progress and response to the intervention. Offering fluids every 2 hours (Choice A) is not directly related to the need for seclusion. Discussing the client's behavior prior to seclusion (Choice C) may not be appropriate at the moment when immediate action is required to prevent harm. Assessing the client's behavior every hour (Choice D) is important but not as immediate as documenting the behavior prior to seclusion.

2. What is the best intervention for a patient with respiratory distress?

• A. Administer oxygen
• B. Administer bronchodilators
• C. Administer IV fluids
• D. Administer corticosteroids

Correct answer: A

Rationale: The correct answer is to administer oxygen. In respiratory distress, the priority intervention is to improve oxygenation. Administering oxygen helps increase the oxygen levels in the blood, supporting respiratory function. While bronchodilators may be used in specific respiratory conditions like asthma or COPD, they are not the primary intervention for respiratory distress. IV fluids are not indicated as the initial treatment for respiratory distress unless there is an underlying cause such as dehydration. Corticosteroids may be used in certain respiratory conditions to reduce inflammation, but they are not the first-line intervention for acute respiratory distress.

3. A nurse is assessing a client who has a new diagnosis of diabetes mellitus. Which of the following findings should the nurse expect?

• A. Increased urinary output.
• B. Weight gain.
• C. Blurred vision.
• D. Diaphoresis.

Correct answer: A

Rationale: Increased urinary output is a common finding in clients with diabetes mellitus due to hyperglycemia and osmotic diuresis. This results in the body trying to eliminate excess glucose through urine, leading to increased urinary frequency and volume. Weight gain is not typically associated with diabetes mellitus but may occur in poorly controlled cases due to increased calorie intake. Blurred vision is more commonly associated with acute complications like hyperglycemia or hypoglycemia. Diaphoresis, or excessive sweating, is not a typical finding in diabetes mellitus but can be seen in conditions like hypoglycemia.

4. A healthcare provider is reviewing the history of a client who is requesting combination oral contraceptives. Which condition in the client's history is a contraindication?

• A. Hyperthyroidism.
• B. Thrombophlebitis.
• C. Diverticulosis.
• D. Hypocalcemia.

Correct answer: B

Rationale: Thrombophlebitis is a contraindication for the use of combination oral contraceptives due to the increased risk of thromboembolic events such as deep vein thrombosis and pulmonary embolism. Hyperthyroidism, diverticulosis, and hypocalcemia are not typically contraindications for using combination oral contraceptives, making choices A, C, and D incorrect.

5. A nurse is planning care for a client who is 6 hours postoperative following a total hip arthroplasty. Which of the following interventions should the nurse include in the plan of care?

• A. Place a wedge under the client's affected leg.
• B. Keep the client's hip flexed at a 90° angle.
• C. Position the client with the legs extended and the hip externally rotated.
• D. Keep the client's leg abductor pillow in place while in bed.

Correct answer: D

Rationale: In caring for a client 6 hours postoperative following a total hip arthroplasty, it is crucial to keep the leg abductor pillow in place while in bed. This intervention helps prevent hip dislocation by maintaining proper alignment and stability of the hip joint. Placing a wedge under the client's affected leg (Choice A) may not provide adequate support and could potentially compromise the surgical site. Keeping the client's hip flexed at a 90° angle (Choice B) or positioning the client with the legs extended and the hip externally rotated (Choice C) are not recommended post total hip arthroplasty as they may increase the risk of hip dislocation.

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