Nursing Elites

1. What intervention is key when managing a client with delirium?

• A. Administer antipsychotic medication to calm the client
• B. Identify any reversible causes of delirium
• C. Provide a low-stimulation environment
• D. Increase environmental stimulation

Correct answer: B

Rationale: The correct intervention when managing a client with delirium is to identify any reversible causes. Delirium can be caused by various factors such as infections, medications, dehydration, or metabolic imbalances. Administering antipsychotic medications (Choice A) may worsen delirium and should be avoided unless necessary for specific indications. Providing a low-stimulation environment (Choice C) is beneficial as it can help reduce agitation and confusion in individuals with delirium. Increasing environmental stimulation (Choice D) is contraindicated as it can exacerbate symptoms in delirious patients. Therefore, the priority should be on identifying and addressing reversible causes to effectively manage delirium.

2. A nurse is caring for a client who is at 41 weeks of gestation and is receiving oxytocin for labor induction. The nurse notes early decelerations on the fetal heart rate monitor. Which of the following nursing actions should the nurse take?

• A. Continue to monitor the fetal heart rate.
• B. Stop the oxytocin infusion.
• C. Perform a vaginal examination.
• D. Initiate an amnioinfusion.

Correct answer: A

Rationale: The correct action for early decelerations, which are caused by fetal head compression and are considered normal during labor, is to continue monitoring the fetal heart rate. Early decelerations mirror contractions and usually do not require any intervention. Stopping the oxytocin infusion (Choice B) is not necessary as early decelerations are not typically a cause for concern related to oxytocin. Performing a vaginal examination (Choice C) or initiating an amnioinfusion (Choice D) are unnecessary and not indicated specifically for early decelerations.

3. What are common risk factors for urinary tract infections (UTIs)?

• A. Poor hygiene and dehydration
• B. Increased sexual activity and pregnancy
• C. Use of urinary catheters and prolonged bed rest
• D. Family history and obesity

Correct answer: A

Rationale: The correct answer is A: Poor hygiene and dehydration are common risk factors for urinary tract infections (UTIs). While choices B, C, and D may play a role in certain cases, poor hygiene and dehydration are more universally recognized as key factors contributing to UTIs. Increased sexual activity and pregnancy (choice B) can also increase the risk of UTIs, but they are not as universal as poor hygiene and dehydration. Choices C and D, the use of urinary catheters and prolonged bed rest, and family history and obesity, respectively, are risk factors for UTIs but are not as commonly associated as poor hygiene and dehydration.

4. What is the most appropriate safety measure for a client using home oxygen?

• A. Store oxygen tanks upright when not in use
• B. Ensure oxygen tanks are kept upright at all times
• C. Allow family members to smoke in designated areas
• D. Keep oxygen equipment at least 10 feet away from heat sources

Correct answer: B

Rationale: The correct answer is to ensure oxygen tanks are kept upright at all times. This is important to prevent the tanks from falling over, which can lead to injuries or tank damage. Choice A is incorrect because oxygen tanks should not be stored in a closet when not in use, as this can lead to poor ventilation and potential hazards. Choice C is incorrect because smoking near oxygen tanks poses a significant fire risk. Choice D is incorrect because while it is important to keep oxygen equipment away from heat sources, ensuring the tanks are kept upright is a more critical safety measure.

5. When should a nurse suction a client with a tracheostomy?

• A. Every 6 hours, regardless of distress signs
• B. When the client's respiratory rate drops below 10
• C. When the client shows signs of irritability
• D. When the client begins to cough or show signs of airway blockage

Correct answer: C

Rationale: The correct answer is to suction the client when they show signs of irritability. Signs of irritability, such as restlessness or agitation, can indicate the need for suctioning in a client with a tracheostomy. This early indicator suggests that there may be an accumulation of secretions affecting the client's airway. Suctioning should be performed promptly to maintain a clear airway and prevent complications. Choices A, B, and D are incorrect because suctioning should be based on clinical signs and symptoms indicating the need for intervention, rather than a fixed schedule or specific vital sign parameters.

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