Nursing Elites

1. A nurse is providing discharge instructions to a client who has a new prescription for codeine for cough suppression. What is the priority instruction?

• A. Avoid driving
• B. Drink plenty of fluids
• C. Move slowly when standing up
• D. Take with food

Correct answer: C

Rationale: The correct answer is to instruct the client to 'Move slowly when standing up.' Codeine can cause orthostatic hypotension, a drop in blood pressure when changing positions, leading to dizziness or fainting. By advising the client to move slowly when standing up, the nurse helps prevent falls or injuries due to sudden drops in blood pressure. Choices A, B, and D are important instructions as well but not the priority when considering the risk of orthostatic hypotension associated with codeine.

2. 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.

3. What is the primary intervention for a client diagnosed with delirium?

• A. Provide a quiet and calm environment to minimize confusion
• B. Administer medication to reverse the symptoms of delirium
• C. Provide opportunities for social interaction to reduce isolation
• D. Encourage the client to remain physically active

Correct answer: A

Rationale: The correct answer is A: Provide a quiet and calm environment to minimize confusion. For clients diagnosed with delirium, creating a tranquil setting can help reduce agitation and disorientation. This intervention aims to decrease stimuli that may exacerbate symptoms. Administering medication (choice B) is not the primary intervention for delirium; it is usually reserved for specific underlying causes. While social interaction (choice C) and physical activity (choice D) are beneficial for overall well-being, they are not the primary interventions for managing delirium.

4. A community health nurse is providing an educational session on childhood poisoning at a local school. What should the nurse advise as the first action if poisoning occurs?

• A. Call the poison control center
• B. Bring the child to the emergency department (ED)
• C. Induce vomiting
• D. Call an ambulance

Correct answer: A

Rationale: In the event of poisoning, the recommended first action is to call the poison control center. Poison control specialists can provide immediate guidance on how to manage the situation effectively. Bringing the child to the emergency department (Choice B) may be necessary depending on the severity of the poisoning, but contacting poison control first is crucial for appropriate and timely intervention. Inducing vomiting (Choice C) is not advised in all cases of poisoning and should only be done under the guidance of healthcare professionals. Calling an ambulance (Choice D) may be necessary in some severe cases, but the initial step should be to contact poison control for expert advice.

5. A client is admitted with a diagnosis of diabetic ketoacidosis (DKA). Which of the following is a priority nursing intervention?

• A. Administer a dextrose 50% IV bolus
• B. Provide 8 oz of orange juice
• C. Administer regular insulin IV infusion
• D. Give oral metformin

Correct answer: C

Rationale: The correct answer is C: Administer regular insulin IV infusion. In diabetic ketoacidosis (DKA), the priority intervention is to rapidly decrease blood glucose levels. Administering regular insulin via IV infusion helps in lowering blood glucose effectively and quickly. Choice A, administering a dextrose 50% IV bolus, is incorrect because it would further increase blood sugar levels. Choice B, providing orange juice, is not appropriate for treating DKA as it contains sugar that will elevate blood glucose levels. Choice D, giving oral metformin, is not suitable for immediate blood glucose reduction as it acts over time and is not the first-line treatment for DKA.

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