Nursing Elites

1. What is the most important nursing action for a patient presenting with confusion after surgery?

• A. Administer oxygen
• B. Reposition the patient
• C. Administer IV fluids
• D. Perform a neurological assessment

Correct answer: A

Rationale: Administering oxygen is crucial for a patient presenting with confusion after surgery because it helps alleviate potential hypoxia, which can be a common cause of confusion in the postoperative period. While repositioning the patient, administering IV fluids, and performing a neurological assessment are important nursing interventions in certain situations, addressing hypoxia by administering oxygen takes priority in this case to ensure an adequate oxygen supply to the brain and other vital organs.

2. A nurse is assessing a client who has cirrhosis. Which of the following findings should the nurse expect?

• A. Clay-colored stools.
• B. Hypertension.
• C. Stridor.
• D. Elevated temperature.

Correct answer: A

Rationale: Clay-colored stools are a classic finding in a client with cirrhosis. Cirrhosis can lead to impaired bile flow, resulting in pale or clay-colored stools due to a lack of bilirubin in the stool. Hypertension, stridor, and elevated temperature are not typically associated with cirrhosis. Hypertension may occur in cirrhosis but is not a consistent finding, stridor is more commonly associated with upper airway obstruction, and elevated temperature may indicate an infection rather than a direct result of cirrhosis.

3. A client receiving radiation therapy for breast cancer may experience which of the following side effects that the nurse should monitor for?

• A. Fatigue
• B. Nausea
• C. Skin irritation
• D. Weight gain

Correct answer: C

Rationale: During radiation therapy for breast cancer, one common side effect is skin irritation due to the impact of radiation on the skin cells. This side effect should be closely monitored by the nurse. Fatigue may also occur as a side effect of radiation therapy, but skin irritation is more specific to the treatment area and is a priority in this case. Nausea and weight gain are not typically associated with radiation therapy for breast cancer, making them incorrect choices.

4. A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

• A. Insert a tongue depressor into the client's mouth.
• B. Restrain the client's arms and legs.
• C. Turn the client onto their side.
• D. Place the client in a prone position.

Correct answer: C

Rationale: During a tonic-clonic seizure, the nurse should turn the client onto their side. This action helps maintain an open airway by allowing saliva or any vomitus to drain out of the mouth, reducing the risk of aspiration. Inserting a tongue depressor (choice A) is incorrect as it can cause injury to the client's mouth and is not recommended during a seizure. Restraining the client's arms and legs (choice B) can lead to physical harm and should be avoided. Placing the client in a prone position (choice D) is dangerous as it can obstruct the airway and hinder breathing, which is not suitable for a client experiencing a seizure.

5. A client who has a new diagnosis of tuberculosis should be placed in which type of room to prevent the spread of airborne pathogens?

• A. Administer isoniazid by mouth daily.
• B. Place the client in droplet isolation.
• C. Wear a surgical mask when transporting the client.
• D. Place the client in a negative pressure room.

Correct answer: D

Rationale: Clients diagnosed with tuberculosis should be placed in a negative pressure room to prevent the spread of airborne pathogens. Option A is incorrect because administering isoniazid is a treatment for tuberculosis, not a preventive measure related to infection control. Option B is incorrect as droplet isolation is used for diseases transmitted through respiratory droplets, not airborne pathogens like tuberculosis. Option C is incorrect as wearing a surgical mask is not sufficient to prevent the spread of tuberculosis in healthcare settings; placing the client in a negative pressure room is the most effective measure.

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