Nursing Elites

1. When providing care for an unconscious client who has seizures, which nursing intervention is most essential?

• A. Ensure oral suction is available.
• B. Maintain the client in a semi-Fowler's position.
• C. Provide frequent mouth care.
• D. Keep the room at a comfortable temperature.

Correct answer: A

Rationale: During seizures in an unconscious client, ensuring oral suction is available is crucial to managing secretions and preventing aspiration. This intervention helps maintain a clear airway and reduce the risk of complications. Maintaining the client in a semi-Fowler's position (Choice B) may be important for airway management but is not as critical as having oral suction ready. Providing frequent mouth care (Choice C) and keeping the room at a comfortable temperature (Choice D) are important aspects of overall care but are not as urgently needed as ensuring oral suction for managing secretions during seizures.

2. A client in a physician’s office has just made an appointment for an exercise stress test. The client should be instructed to:

• A. Wear sweatpants and a heavy sweatshirt
• B. Eat a small meal just before the procedure
• C. Wear comfortable rubber-soled shoes such as sneakers
• D. Avoid consuming caffeine for 30 minutes before the procedure

Correct answer: C

Rationale: The client should wear comfortable rubber-soled shoes, such as sneakers, for the exercise stress test. This choice ensures safety and stability during the procedure. Wearing sweatpants and a heavy sweatshirt (Choice A) would not be appropriate as the client needs to wear light, loose, comfortable clothing. Eating a small meal just before the procedure (Choice B) could lead to discomfort during the test. Avoiding caffeine for 30 minutes before the procedure (Choice D) is not a specific instruction related to the attire or preparation for the test.

3. A healthcare professional reviews the blood gas results of a client in respiratory distress. The pH is 7.32, and the PCO2 is 50 mm Hg. Which of the following acid-base imbalances does the professional recognize in these findings?

• A. Metabolic acidosis
• B. Metabolic alkalosis
• C. Respiratory acidosis
• D. Respiratory alkalosis

Correct answer: C

Rationale: In respiratory acidosis, the pH is low (<7.35) and the PCO2 is increased (>45 mm Hg). These findings indicate that the client is experiencing respiratory acidosis, a condition where there is an excess of carbon dioxide in the blood due to inadequate ventilation, commonly seen in respiratory distress. Metabolic acidosis (Choice A) is characterized by a low pH and decreased bicarbonate levels, which is not the case in this scenario. Metabolic alkalosis (Choice B) is associated with a high pH and increased bicarbonate levels. Respiratory alkalosis (Choice D) is marked by a high pH and decreased PCO2, opposite to the values presented in the blood gas results of this client.

4. A patient asks the nurse about taking calcium supplements to avoid hypocalcemia. The nurse will suggest that the patient follow which instruction?

• A. Take a calcium and vitamin D combination supplement.
• B. Take calcium along with phosphorus to improve absorption.
• C. Take calcium with antacids to reduce stomach upset.
• D. Use aspirin instead of acetaminophen when taking calcium.

Correct answer: A

Rationale: The correct answer is to take a calcium and vitamin D combination supplement. Vitamin D enhances the absorption of calcium in the body, making it an essential component for calcium utilization. Choice B is incorrect because calcium and phosphorus have an inverse relationship, where an increased level of one mineral decreases the level of the other, so taking them together may not be beneficial. Choice C is incorrect because antacids often contain magnesium, which can promote calcium loss instead of absorption. Choice D is incorrect because aspirin can alter vitamin D levels and interfere with calcium absorption, so it is not recommended when taking calcium supplements.

5. After the administration of t-PA, what should the nurse do?

• A. Observe the client for chest pain.
• B. Monitor for fever.
• C. Review the 12-lead electrocardiogram (ECG).
• D. Auscultate breath sounds.

Correct answer: A

Rationale: After the administration of t-PA, the nurse should observe the client for chest pain. Chest pain post t-PA administration could indicate reocclusion of the coronary artery, a serious complication that requires immediate intervention. Monitoring for fever (choice B) is not specifically associated with t-PA administration. While reviewing the 12-lead ECG (choice C) is important for assessing cardiac function, it may not be the immediate priority right after t-PA administration. Auscultating breath sounds (choice D) is important for assessing respiratory status but is not the most crucial assessment following t-PA administration.

Similar Questions