Nursing Elites

1. The nurse is caring for a manic client in the seclusion room, and it is time for lunch. It is MOST appropriate for the nurse to take which of the following actions?

• A. Take the client to the dining room with 1:1 supervision
• B. Inform the client they may go to the dining room when they control their behavior
• C. Hold the meal until the client is able to come out of seclusion
• D. Serve the meal to the client in the seclusion room

Correct answer: D

Rationale: In the scenario described, the manic client is in the seclusion room, and it is most appropriate for the nurse to serve the meal to the client in the seclusion room. This action helps maintain the client's nutritional needs while managing their behavior. Taking the client to the dining room with 1:1 supervision (Choice A) may pose safety risks both for the client and others. Informing the client they may go to the dining room when they control their behavior (Choice B) may not be feasible in a manic state. Holding the meal until the client is able to come out of seclusion (Choice C) can lead to nutritional deficiencies and does not address the immediate need for nutrition during the episode of mania.

2. A client has undergone a bronchoscopy, and a nurse is providing care post-procedure. What should the nurse do first?

• A. Monitor the client's oxygen levels
• B. Encourage the client to eat
• C. Check for a gag reflex
• D. Administer IV fluids

Correct answer: C

Rationale: After a bronchoscopy, the nurse's priority is to check for a gag reflex. This action helps assess the client's ability to protect their airway after sedation. Maintaining airway patency is crucial post-procedure. Monitoring oxygen levels is important but ensuring airway protection takes precedence. Encouraging the client to eat and administering IV fluids are essential aspects of care but are not the immediate priority in this situation.

3. A healthcare professional is reviewing the laboratory report of a client who is receiving filgrastim. Which of the following laboratory values should the healthcare professional monitor to determine the effectiveness of the treatment?

• A. WBC count.
• B. Serum potassium.
• C. Hemoglobin level.
• D. Serum creatinine.

Correct answer: A

Rationale: Filgrastim works by stimulating the production of white blood cells. Therefore, monitoring the white blood cell (WBC) count is essential to assess the effectiveness of the treatment. Choice B, serum potassium, is not directly affected by filgrastim therapy. Choice C, hemoglobin level, is important but not the primary indicator of filgrastim's effectiveness. Choice D, serum creatinine, is unrelated to the action of filgrastim and would not reflect its effectiveness.

4. What is a key nursing action for a client with a wound infection?

• A. Change the dressing daily
• B. Perform a wound culture before applying antibiotics
• C. Cleanse the wound with alcohol-based solutions
• D. Apply a wet-to-dry dressing to the wound

Correct answer: B

Rationale: Performing a wound culture before applying antibiotics is crucial for determining the specific type of infection present and selecting the most effective antibiotic treatment. Changing the dressing daily (Choice A) is a routine wound care practice but may not address the root cause of the infection. Cleansing the wound with alcohol-based solutions (Choice C) can be too harsh and delay wound healing. Applying a wet-to-dry dressing (Choice D) is an outdated practice that can cause trauma to the wound bed and hinder the healing process.

5. A nurse is caring for a client who has heart failure and is receiving digoxin. Which of the following findings should the nurse identify as a sign of digoxin toxicity?

• A. Bradycardia
• B. Tachycardia
• C. Hypotension
• D. Increased appetite

Correct answer: A

Rationale: Corrected Rationale: Bradycardia is a common sign of digoxin toxicity. Digoxin, a medication used to treat heart failure, works by slowing down the heart rate and increasing the force of heart contractions. Excessive levels of digoxin can lead to toxicity, causing bradycardia (slow heart rate), among other symptoms. Tachycardia (fast heart rate) and hypotension (low blood pressure) are not typically associated with digoxin toxicity. Increased appetite is not a recognized sign of digoxin toxicity; instead, gastrointestinal symptoms like nausea, vomiting, and anorexia are more common.

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