Nursing Elites

1. What is the most appropriate action for a healthcare provider to take when a patient is experiencing a seizure?

• A. Protect the patient's head
• B. Restrain the patient's movements
• C. Insert an airway
• D. Give the patient water

Correct answer: A

Rationale: During a seizure, the most appropriate action for a healthcare provider is to protect the patient's head. This helps prevent injury, especially considering the involuntary movements and potential thrashing associated with seizures. Restraint should be avoided as it can lead to further injury or distress for the patient. Inserting an airway is not recommended during an active seizure as the patient's airway may not be obstructed, and it could pose a risk of injury. Giving the patient water during a seizure is also not advisable as there is a risk of aspiration. Therefore, the priority is to ensure the patient's safety by protecting their head.

2. When providing family education for those who have a relative with Alzheimer's disease about minimizing stress, which of the following suggestions is most relevant?

• A. Allow the client to rest four to five times during the day
• B. Assess the cognitive functioning of the client regularly
• C. Provide reality orientation even if the memory loss is severe
• D. Maintain consistency in environment, routine, and caregivers

Correct answer: D

Rationale: The most relevant suggestion for minimizing stress in individuals with Alzheimer's disease is to maintain consistency in the environment, routine, and caregivers. This approach helps create a sense of familiarity and security for the individual, reducing stress and anxiety. Choice A is incorrect as it suggests allowing the client to go to bed multiple times during the day, which may disrupt their routine and lead to confusion. Choice B is incorrect as continuously testing cognitive functioning can be overwhelming and stressful for the individual. Choice C is also incorrect as providing reality orientation in cases of severe memory loss can cause frustration and confusion, ultimately increasing stress levels.

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 the best approach to assist a client in performing self-care after an acute myocardial infarction, when the client expresses concern about fatigue?

• A. Provide clear instructions on how to ask for assistance
• B. Gradually resume self-care tasks, focusing on rest periods
• C. Encourage assistive personnel to complete self-care tasks
• D. Encourage the client to remain in bed until fully rested

Correct answer: B

Rationale: The best approach to assist a client in performing self-care after an acute myocardial infarction, especially when the client expresses concern about fatigue, is to gradually resume self-care tasks while focusing on rest periods. This approach allows the client to build confidence in managing their self-care activities while also addressing the issue of fatigue. Choice A is incorrect as it focuses on asking for assistance rather than promoting self-care. Choice C is inappropriate as it suggests delegating the client's self-care tasks to assistive personnel instead of empowering the client. Choice D is incorrect as it can lead to deconditioning and is not conducive to the client's recovery process.

5. A nurse on an acute unit has received a change of shift report for 4 clients. Which of the following clients should the nurse assess first?

• A. A client who is 1 hr postoperative and has hypoactive bowel sounds.
• B. A client who has a fractured left tibia and pallor in the affected extremity.
• C. A client who had a cardiac catheterization 3 hr ago and has 3+ pedal pulses.
• D. A client who has an elevated AST level following the administration of azithromycin.

Correct answer: B

Rationale: The correct answer is B because pallor in an extremity after a fracture could indicate compromised circulation, making it a priority for assessment. Choice A is not the priority as hypoactive bowel sounds in a client 1 hr postoperative, while concerning, do not indicate a life-threatening condition. Choice C, a client who had a cardiac catheterization 3 hr ago and has 3+ pedal pulses, indicates good perfusion and does not require immediate attention. Choice D, a client with an elevated AST level following the administration of azithromycin, may require further assessment but is not as urgent as the client with potential compromised circulation in choice B.

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