Nursing Elites

1. What is the most appropriate response when a client wants to discontinue dialysis?

• A. Ask the client why they want to discontinue.
• B. Instruct the client to focus on self-care.
• C. Offer to call the provider to cancel dialysis.
• D. Seek clarification and establish understanding.

Correct answer: D

Rationale: When a client expresses the desire to discontinue dialysis, the most appropriate response is to seek clarification and establish understanding. This approach allows the healthcare provider to comprehend the client's concerns, provide support, and engage in a collaborative decision-making process. Choice A, asking the client why they want to discontinue, can be perceived as confrontational and may not effectively address the underlying reasons. Instructing the client to focus on self-care (Choice B) may overlook the client's autonomy and decision-making capacity. Offering to call the provider to cancel dialysis (Choice C) does not actively involve the client in the decision-making process or address their concerns adequately.

2. A nurse in a long-term care facility is observing a newly licensed nurse who is providing tracheostomy care for a client. The nurse identifies proper performance of the procedure when the newly licensed nurse selects which of the following solutions to clean the inner cannula?

• A. Normal saline
• B. Hydrogen peroxide
• C. Iodine
• D. Alcohol

Correct answer: B

Rationale: The correct answer is B: Hydrogen peroxide. Hydrogen peroxide is commonly used to clean tracheostomy cannulas to prevent infection. Normal saline (choice A) is used for wound irrigation but not for cleaning inner cannulas of tracheostomy tubes. Iodine (choice C) and alcohol (choice D) are not recommended for cleaning tracheostomy cannulas as they can be too harsh and irritating to the delicate tissues of the airway.

3. A nurse is collecting data from a client who is in severe pain. Which of the following questions should the nurse ask first?

• A. When did your pain start?
• B. How severe is your pain?
• C. What makes your pain worse?
• D. Where is your pain located?

Correct answer: D

Rationale: The nurse should first ask the client where the pain is located because identifying the location of the pain is crucial in determining the cause and appropriate treatment. This information helps in further assessment and diagnosis. Asking when the pain started (Choice A) may be important but determining the location provides more immediate insights. Inquiring about the severity of pain (Choice B) and what worsens it (Choice C) are also important but come after identifying the location to provide a comprehensive understanding of the client's condition.

4. What are the complications of untreated fluid overload?

• A. Pulmonary edema and congestive heart failure
• B. Hypertension and electrolyte imbalance
• C. Liver failure and electrolyte imbalance
• D. Pulmonary embolism and dehydration

Correct answer: A

Rationale: Corrected Rationale: Untreated fluid overload can lead to complications such as pulmonary edema and congestive heart failure. Pulmonary edema occurs when excess fluid accumulates in the lungs, leading to difficulty breathing and potentially life-threatening respiratory distress. Congestive heart failure can result from the heart's inability to pump effectively due to the excess fluid volume, leading to symptoms such as fatigue, shortness of breath, and fluid retention. Choices B, C, and D are incorrect because hypertension, liver failure, pulmonary embolism, and dehydration are not the primary complications directly associated with untreated fluid overload.

5. How should a healthcare provider respond to a patient experiencing a seizure?

• A. Protect the airway and monitor for post-ictal confusion
• B. Administer anticonvulsant medications
• C. Apply restraints to prevent injury
• D. Place the patient in a side-lying position

Correct answer: D

Rationale: When a patient is experiencing a seizure, the immediate priority is to ensure their safety by placing them in a side-lying position. This helps prevent aspiration in case of vomiting and maintains an open airway. Administering anticonvulsant medications is not within the scope of a healthcare provider's immediate response during a seizure. Applying restraints can potentially harm the patient by restricting movement and causing injury. Monitoring for post-ictal confusion is important after the seizure has ended, but the primary concern during the seizure is ensuring the patient's safety.

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