Nursing Elites

1. During the admission interview, an older client answers some questions inappropriately. The nurse notes that a hearing aid is in one ear. Which intervention is most helpful in assisting the client to hear the nurse’s question?

• A. Move to the client's other side.
• B. Speak louder into the client's ear with the hearing aid.
• C. Ask the client to adjust the hearing aid volume.
• D. Restate questions articulating consonants carefully.

Correct answer: D

Rationale: Restating questions with clear articulation is the most helpful intervention in assisting the client to hear the nurse's question. This approach ensures that the client can better understand the question, especially if there are issues with the hearing aid. Moving to the client's other side or speaking louder into the ear with the hearing aid may not effectively address the problem of clarity in communication. Asking the client to adjust the hearing aid volume assumes that the issue lies solely with the volume, while restating questions with clear articulation can help overcome various hearing difficulties.

2. The nurse is assessing a client who reports sudden onset of severe eye pain and blurred vision. What is the priority nursing intervention?

• A. Administer prescribed pain medication.
• B. Notify the healthcare provider immediately.
• C. Place an eye patch over the affected eye.
• D. Prepare the client for a CT scan.

Correct answer: B

Rationale: The correct answer is to notify the healthcare provider immediately (Choice B). Sudden severe eye pain and blurred vision can indicate acute angle-closure glaucoma, which is a medical emergency requiring prompt evaluation and treatment to prevent vision loss. Administering pain medication (Choice A) may provide temporary relief but does not address the underlying cause. Placing an eye patch (Choice C) may not be appropriate without knowing the exact cause of the symptoms. Preparing for a CT scan (Choice D) is not the immediate priority in this situation where urgent medical attention is needed.

3. A client who is newly diagnosed with emphysema is being prepared for discharge. Which instruction is best for the nurse to provide the client to assist them with dyspnea self-management?

• A. Allow additional time to complete physical activities to reduce oxygen demand.
• B. Practice inhaling through the nose and exhaling slowly through pursed lips.
• C. Use a humidifier to increase home air quality humidity between 30-50%.
• D. Strengthen abdominal muscles by alternating leg raises during exhalation.

Correct answer: B

Rationale: The correct answer is B. Instructing the client to practice inhaling through the nose and exhaling slowly through pursed lips can help improve oxygenation and reduce dyspnea. This technique, known as pursed lip breathing, can help regulate breathing patterns and decrease the work of breathing in clients with emphysema. Choice A is incorrect because allowing additional time for physical activities does not directly address dyspnea management. Choice C is incorrect as using a humidifier, although beneficial for respiratory conditions, does not specifically assist with dyspnea self-management. Choice D is also incorrect as strengthening abdominal muscles through leg raises does not directly target dyspnea relief.

4. What is the most effective therapy for maintaining remission of acute lymphoblastic leukemia in a child?

• A. Surgery to remove enlarged lymph nodes
• B. Long-term chemotherapy
• C. Nutritional supplements to enhance blood cell production
• D. Blood transfusions to replace ineffective red cells

Correct answer: B

Rationale: The correct answer is B: Long-term chemotherapy. In the case of acute lymphoblastic leukemia, the most effective approach for maintaining remission is long-term chemotherapy, particularly with methotrexate, a chemotherapeutic agent. Surgery to remove enlarged lymph nodes (choice A) is not the primary treatment for leukemia. Nutritional supplements (choice C) may be beneficial for overall health but are not the mainstay of leukemia treatment. Blood transfusions (choice D) are used to manage anemia in leukemia but do not address the underlying disease process.

5. A male client with diabetes mellitus is transferred from the hospital to a rehabilitation facility following treatment for a stroke resulting in right hemiplegia. He tells the nurse that his feet are always uncomfortably cool at night, preventing him from falling asleep. Which action should the nurse implement?

• A. Provide a warming pad for his feet
• B. Medicate the client with a prescribed sedative.
• C. Use a bed cradle to keep the covers off his feet.
• D. Place warm blankets next to the client's feet.

Correct answer: D

Rationale: Placing warm blankets next to the client's feet is the most appropriate action to provide warmth and comfort. This method is safe and effective in addressing the client's complaint of uncomfortably cool feet at night. Providing a warming pad (Choice A) may pose a risk of burns or injury, especially for a client with decreased sensation due to diabetes. Mediating the client with a sedative (Choice B) does not address the underlying issue of cool feet and may not be necessary. Using a bed cradle (Choice C) to hold the covers off the feet does not directly address the client's need for warmth and comfort.

Similar Questions