Nursing Elites

1. A patient is experiencing shortness of breath. What is the nurse's immediate action?

• A. Assist the patient into a high Fowler's position.
• B. Administer oxygen at 2 liters per minute via nasal cannula.
• C. Encourage the patient to take deep breaths and cough.
• D. Assess the patient's lung sounds.

Correct answer: B

Rationale: Administering oxygen at 2 liters per minute via nasal cannula is the immediate action for a patient experiencing shortness of breath. This intervention helps to improve oxygenation and relieve respiratory distress promptly. Placing the patient in a high Fowler's position (choice A) may also be beneficial but providing oxygen takes precedence in this scenario to address the underlying hypoxemia. Encouraging deep breaths and coughing (choice C) may not be appropriate as the first action, especially without assessing the patient first. Assessing lung sounds (choice D) is essential but should follow the initial intervention of administering oxygen.

2. What is a primary goal when managing a client with generalized anxiety disorder (GAD)?

• A. Encourage the client to engage in regular physical exercise
• B. Help the client avoid anxiety triggers through behavioral therapy
• C. Encourage the client to express feelings openly
• D. Teach relaxation techniques to help manage anxiety

Correct answer: D

Rationale: When managing a client with generalized anxiety disorder (GAD), a primary goal is to teach relaxation techniques to help manage anxiety. Relaxation techniques such as deep breathing, progressive muscle relaxation, and mindfulness can be effective in reducing anxiety symptoms. Encouraging the client to engage in regular physical exercise (Choice A) can be beneficial but teaching relaxation techniques is more specific to managing anxiety. Avoiding anxiety triggers through behavioral therapy (Choice B) may be part of the treatment plan but teaching relaxation techniques is more directly aimed at managing anxiety. While encouraging the client to express feelings openly (Choice C) can be important for overall emotional well-being, teaching relaxation techniques is more focused on addressing the symptoms of anxiety.

3. While caring for a client receiving morphine, what assessment is the priority for a nurse to conduct?

• A. Blood pressure
• B. Heart rate
• C. Respiratory rate
• D. Temperature

Correct answer: C

Rationale: The correct answer is monitoring the respiratory rate. Morphine can depress respiratory function, leading to respiratory depression or arrest. Therefore, closely monitoring the client's respiratory rate is crucial to detect any signs of respiratory distress. While blood pressure, heart rate, and temperature are important assessments, in this scenario, respiratory rate takes precedence due to the potential respiratory complications associated with morphine administration.

4. Which action should the nurse take to minimize the risk of medication errors?

• A. Prepare medications ahead of time to ensure they are ready.
• B. Ensure two nurses double-check medications before administration.
• C. Administer medications at the same time each day.
• D. Rely on memory to administer the correct medications.

Correct answer: B

Rationale: The correct answer is B because ensuring two nurses double-check medications before administration is a crucial step in minimizing the risk of medication errors. This practice helps in verifying the accuracy of medication orders and reducing the chances of mistakes. Choice A may not necessarily prevent errors as preparing medications ahead of time does not guarantee accuracy. Choice C, administering medications at the same time each day, is important for consistency but does not directly address the risk of errors. Choice D, relying on memory, is highly discouraged as it increases the likelihood of errors due to human forgetfulness.

5. A patient has impaired skin integrity, and a nurse is providing care. What action should the nurse take to promote healing?

• A. Apply a dry, sterile dressing to the wound.
• B. Use sterile saline to clean the wound.
• C. Apply a warm compress to promote circulation.
• D. Keep the wound open to air for faster healing.

Correct answer: B

Rationale: The correct action to promote healing in a patient with impaired skin integrity is to use sterile saline to clean the wound. Sterile saline helps prevent infection and promotes healing of wounds by keeping the area clean. Applying a dry, sterile dressing (Choice A) may not be effective as it does not address the need for wound cleaning. Applying a warm compress (Choice C) may not be suitable for all types of wounds and could potentially cause harm. Keeping the wound open to air (Choice D) is generally not recommended as it can lead to infection and slow down the healing process.

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