Nursing Elites

1. What intervention should the nurse implement for a client experiencing an anxiety attack?

• A. Teach deep breathing exercises
• B. Provide a quiet environment
• C. Administer anxiolytic medication as prescribed
• D. Engage the client in conversation

Correct answer: C

Rationale: Administering prescribed anxiolytic medication is the most appropriate intervention for a client experiencing an anxiety attack. Anxiolytic medications can provide rapid relief from severe anxiety symptoms. Teaching deep breathing exercises (choice A) can be helpful for managing mild anxiety but may not be sufficient during an acute anxiety attack. Providing a quiet environment (choice B) is beneficial to reduce stimuli, but it may not address the immediate distress of an ongoing anxiety attack. Engaging the client in conversation (choice D) is generally not recommended during an anxiety attack as it can potentially exacerbate the symptoms by increasing stimulation.

2. The nurse is assessing a client with a suspected pulmonary embolism (PE). Which symptom is most indicative of this condition?

• A. Bilateral leg swelling.
• B. Sudden onset of chest pain.
• C. Gradual onset of dyspnea.
• D. Decreased breath sounds on auscultation.

Correct answer: C

Rationale: The correct answer is C: 'Gradual onset of dyspnea.' While pulmonary embolism can present with various symptoms, the most common include sudden onset of dyspnea, chest pain (often pleuritic in nature), tachypnea, and tachycardia. Bilateral leg swelling is more commonly associated with conditions like deep vein thrombosis, not pulmonary embolism. Decreased breath sounds on auscultation may be seen in conditions like pneumothorax, not typically in pulmonary embolism. Therefore, the gradual onset of dyspnea is the most indicative symptom of pulmonary embolism in this scenario.

3. A client with type 1 diabetes is experiencing symptoms of hypoglycemia. What is the nurse's priority intervention?

• A. Administer glucagon intramuscularly
• B. Provide a complex carbohydrate snack
• C. Administer 50% dextrose intravenously
• D. Give 15 grams of a fast-acting carbohydrate

Correct answer: D

Rationale: The priority intervention for a client with type 1 diabetes experiencing symptoms of hypoglycemia is to give 15 grams of a fast-acting carbohydrate. In a hypoglycemic state, the priority is to quickly raise the blood glucose level. Administering glucagon intramuscularly (Choice A) is reserved for severe hypoglycemia when the client is unable to take oral carbohydrates. Providing a complex carbohydrate snack (Choice B) is beneficial after the initial treatment of hypoglycemia to prevent recurrence. Administering 50% dextrose intravenously (Choice C) is a more invasive intervention typically done in a hospital setting for severe cases.

4. When assisting a client to obtain a sputum specimen, the nurse observes the client cough and spit a large amount of frothy saliva in the specimen collection cup. What action should the nurse implement next?

• A. Advise the client that suctioning will be used to obtain another specimen
• B. Re-instruct the client in coughing techniques to obtain another specimen
• C. Provide the client a glass of water and mouthwash to rinse the mouth
• D. Label the container and place the container in a biohazard transport bag

Correct answer: C

Rationale: After observing the client cough and produce frothy saliva in the collection cup, the nurse should provide the client with a glass of water and mouthwash to rinse the mouth. This action helps clear the mouth of contaminants, ensuring a more accurate sputum specimen for diagnostic testing. Option A is incorrect because suctioning is not the appropriate next step in this situation. Option B is unnecessary as re-instructing the client in coughing techniques may not address the immediate issue of contaminated saliva in the specimen. Option D is premature since labeling and transporting the container should only be done after obtaining a valid specimen.

5. The healthcare provider is assessing a client who has just undergone abdominal surgery. Which finding should be reported to the healthcare provider immediately?

• A. Absence of bowel sounds
• B. Mild abdominal distention
• C. Drainage of serosanguineous fluid from the incision
• D. Sudden onset of severe abdominal pain

Correct answer: D

Rationale: Sudden onset of severe abdominal pain may indicate complications such as peritonitis, bowel perforation, or internal bleeding. These conditions are serious and require immediate medical attention to prevent further complications or deterioration. Absence of bowel sounds, mild abdominal distention, and drainage of serosanguineous fluid are common findings after abdominal surgery and may not necessarily indicate an emergency situation requiring immediate reporting to the healthcare provider. Severe abdominal pain post-surgery should always be reported promptly as it could signify a life-threatening situation that needs urgent evaluation and intervention.

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