Nursing Elites

1. What is the priority in managing a client diagnosed with delirium?

• A. Administer anti-anxiety medication
• B. Identify any underlying causes of delirium
• C. Reduce environmental stimulation to calm the client
• D. Encourage deep breathing exercises

Correct answer: B

Rationale: The priority in managing a client diagnosed with delirium is to identify any underlying causes. Delirium can be caused by various factors such as infections, medications, or metabolic imbalances. By determining the root cause, healthcare providers can address the issue effectively and tailor the treatment plan accordingly. Administering anti-anxiety medication (Choice A) may help manage symptoms but does not address the underlying cause of delirium. Similarly, reducing environmental stimulation (Choice C) and encouraging deep breathing exercises (Choice D) may provide some relief, but they do not target the primary concern of identifying and addressing the underlying causes of delirium.

2. A client post-lumbar puncture should be in which position?

• A. High Fowler's position
• B. Prone position
• C. Supine position
• D. Sitting position

Correct answer: C

Rationale: The most appropriate position for a client post-lumbar puncture is the supine position. Placing the client in a supine position helps prevent spinal headaches by allowing the puncture site to seal effectively and reducing the risk of cerebrospinal fluid leakage. High Fowler's position, prone position, and sitting position are not recommended after a lumbar puncture as they may increase the risk of complications like spinal headaches.

3. What is the nurse's priority when caring for a client with a tracheostomy who is showing signs of respiratory distress?

• A. Administer a bronchodilator
• B. Suction the tracheostomy
• C. Notify the physician immediately
• D. Increase the oxygen flow rate

Correct answer: B

Rationale: The correct answer is to suction the tracheostomy. When a client with a tracheostomy is experiencing respiratory distress, the priority intervention is to clear the airway by suctioning the tracheostomy to remove secretions that may be obstructing the air passage. Administering a bronchodilator (Choice A) may be considered if bronchospasm is present, but the immediate focus should be on clearing the airway. Notifying the physician (Choice C) is important but should not delay the immediate intervention of suctioning. Increasing the oxygen flow rate (Choice D) may provide temporary relief, but addressing the root cause of the distress by suctioning is the priority.

4. A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the following goals should the nurse include in the teaching?

• A. HbA1c level greater than 8%.
• B. Blood glucose level greater than 200 mg/dL at bedtime.
• C. Blood glucose level less than 60 mg/dL before breakfast.
• D. HbA1c level less than 7%.

Correct answer: D

Rationale: The correct answer is D. An HbA1c level less than 7% indicates good long-term glucose control for clients with diabetes. This goal reflects optimal glycemic control and reduces the risk of long-term complications. Choices A, B, and C are incorrect because they do not represent appropriate goals for managing type 1 diabetes in an adolescent. An HbA1c level greater than 8% (choice A) signifies poor glucose control, while a blood glucose level greater than 200 mg/dL at bedtime (choice B) and a blood glucose level less than 60 mg/dL before breakfast (choice C) are not within the target ranges for safe and effective diabetes management.

5. A client receiving chemotherapy reports nausea and vomiting. What is the nurse's priority intervention?

• A. Administer antiemetic medication before meals
• B. Encourage the client to eat small, frequent meals
• C. Instruct the client to avoid eating during treatment
• D. Provide the client with cold beverages during meals

Correct answer: A

Rationale: The correct answer is A: Administer antiemetic medication before meals. When a client receiving chemotherapy reports nausea and vomiting, administering antiemetic medication before meals is a priority intervention to help reduce nausea associated with chemotherapy. This proactive approach can prevent or minimize the symptoms, improving the client's quality of life during treatment. Choice B is incorrect because while encouraging the client to eat small, frequent meals can be helpful, administering antiemetic medication is the priority to address the immediate symptoms. Choice C is incorrect as avoiding eating during treatment may lead to nutritional deficits, and choice D is incorrect because providing cold beverages during meals may not effectively address the nausea and vomiting symptoms.

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