Nursing Elites

1. A nurse is teaching a client with diabetes about insulin administration. What is the most important point to emphasize?

• A. Check blood sugar once in the morning
• B. Administer insulin before meals as prescribed
• C. Administer insulin only when feeling unwell
• D. Monitor blood sugar only in the evening

Correct answer: B

Rationale: The most important point to emphasize when teaching a client with diabetes about insulin administration is to administer insulin before meals as prescribed. This is crucial for maintaining proper blood sugar control throughout the day. Choice A is incorrect because blood sugar levels need to be monitored multiple times a day, not just once in the morning. Choice C is incorrect because insulin should be administered according to the prescribed schedule, not only when feeling unwell. Choice D is incorrect because blood sugar monitoring should be done at various times during the day, not just in the evening.

2. A client with a tracheostomy is exhibiting signs of respiratory distress. What is the first action the nurse should take?

• A. Increase the suction setting on the ventilator
• B. Suction the tracheostomy
• C. Notify the physician immediately
• D. Encourage deep breathing exercises

Correct answer: B

Rationale: The correct first action for a client with a tracheostomy exhibiting signs of respiratory distress is to suction the tracheostomy. This helps clear the airway and improve breathing. Increasing the suction setting on the ventilator is not appropriate as the issue may be related to secretions that need to be directly removed. Notifying the physician should come after providing immediate nursing interventions. Encouraging deep breathing exercises is not suitable when the client is in respiratory distress and needs prompt intervention.

3. A nurse is caring for a client who has dementia and frequently gets out of bed unsupervised. What is the best intervention to prevent falls?

• A. Place a bed exit alarm
• B. Use restraints to prevent the client from getting out of bed
• C. Ask the client's family to stay at the bedside
• D. Encourage frequent ambulation with assistance

Correct answer: A

Rationale: The best intervention to prevent falls in a client with dementia who gets out of bed unsupervised is to place a bed exit alarm. This device alerts staff when the client attempts to leave the bed, allowing timely intervention to reduce the risk of falls. Using restraints (choice B) can lead to physical and psychological harm and should be avoided unless absolutely necessary. Asking the client's family to stay at the bedside (choice C) may not be feasible at all times and does not provide a continuous monitoring solution. Encouraging frequent ambulation with assistance (choice D) is beneficial for mobility but may not address the immediate risk of falls associated with unsupervised bed exits.

4. A nurse assisting with a childbirth class is discussing nonpharmacological strategies used during labor. Which of the following statements by a client indicates an understanding of cutaneous stimulation?

• A. Apply counter-pressure for back pain
• B. Use deep breathing exercises
• C. Visualize the baby's head
• D. Use massage therapy

Correct answer: A

Rationale: The correct answer is A: 'Apply counter-pressure for back pain.' Counter-pressure involves applying pressure to the lower back to alleviate pain during labor. This technique is a form of cutaneous stimulation, which can help with pain relief. Choice B, deep breathing exercises, is a form of relaxation technique and does not directly involve cutaneous stimulation. Choice C, visualizing the baby's head, is a mental imagery technique and does not involve physical stimulation of the skin. Choice D, massage therapy, is a tactile stimulation technique but is not specifically focused on back pain relief through counter-pressure.

5. A nurse is caring for a client with a chest tube post-surgery. What is the most important assessment?

• A. Ensure the chest tube is clamped periodically
• B. Check for air leaks and ensure proper chest tube function
• C. Encourage deep breathing and coughing every 2 hours
• D. Ensure the client is positioned in a high Fowler's position

Correct answer: B

Rationale: The correct answer is B: 'Check for air leaks and ensure proper chest tube function.' This is the most important assessment for a client with a chest tube post-surgery because it ensures that the chest tube is functioning properly. Checking for air leaks helps prevent complications such as pneumothorax or hemothorax. Choice A is incorrect because clamping the chest tube periodically can lead to serious complications and should not be done unless specifically ordered by a healthcare provider. Choice C is important for promoting lung expansion but is not the most critical assessment related to the chest tube. Choice D is also important for respiratory function but is not the priority when assessing a chest tube post-surgery.

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