Nursing Elites

1. Which nursing intervention is best for a client with constipation?

• A. Encourage the client to remain in bed to avoid straining
• B. Administer a stool softener as prescribed
• C. Increase fiber intake through dietary changes
• D. Encourage regular exercise to promote bowel movement

Correct answer: C

Rationale: Increasing fiber intake is the most appropriate nursing intervention for a client experiencing constipation. Fiber helps add bulk to the stool, making it easier to pass and promoting regular bowel movements. Encouraging the client to remain in bed may exacerbate constipation by reducing movement and promoting inactivity. While stool softeners can be beneficial, they are typically used as a short-term solution and may not address the underlying issue of low fiber intake. Regular exercise is important for overall bowel health; however, in the immediate management of constipation, increasing fiber intake is the most effective intervention.

2. A nurse is reviewing the plan of care for a client undergoing radiation therapy for cancer. Which of the following instructions should the nurse reinforce with the client?

• A. Apply sunscreen before going outside
• B. Avoid using perfumed lotions
• C. Massage the area daily
• D. Take vitamin supplements with food

Correct answer: B

Rationale: The correct instruction the nurse should reinforce with the client undergoing radiation therapy is to avoid using perfumed lotions. This is essential to reduce the risk of skin irritation, as perfumed lotions can exacerbate skin reactions during radiation therapy. Applying sunscreen before going outside is generally a good practice but not specifically related to radiation therapy. Massaging the area daily is contraindicated during radiation therapy as it can further irritate the skin. Taking vitamin supplements with food is important for overall health but is not a specific instruction related to radiation therapy.

3. How should a healthcare professional assess a patient with chest pain?

• A. Assess the severity of pain and monitor ECG
• B. Administer nitroglycerin and provide oxygen
• C. Administer aspirin and provide pain relief
• D. Monitor for nausea and administer IV fluids

Correct answer: A

Rationale: When assessing a patient with chest pain, the initial step is to assess the severity of pain and monitor the electrocardiogram (ECG) to look for signs of cardiac issues. Administering nitroglycerin and oxygen (Choice B) is a treatment option for suspected cardiac chest pain but should not precede a thorough assessment. Administering aspirin and providing pain relief (Choice C) may be indicated later, but the priority is to assess the situation first. Monitoring for nausea and administering IV fluids (Choice D) is not the initial assessment for chest pain unless there are specific indications present.

4. When a client with dementia frequently becomes agitated, what should the nurse prioritize investigating?

• A. Fluid and electrolyte imbalances
• B. Medication history
• C. Environmental factors
• D. Cognitive functioning

Correct answer: B

Rationale: The correct answer is to prioritize investigating the client's medication history. This is important because certain medications can contribute to agitation in clients with dementia. Understanding the medication history can help identify potential causes of agitation and guide appropriate interventions. Checking for fluid and electrolyte imbalances is important in healthcare but may not directly relate to the client's agitation. While environmental factors can influence behavior, investigating the medication history is more pertinent in this case. Cognitive functioning assessment is crucial in dementia care but may not be the priority when addressing acute agitation.

5. When managing a physically assaultive client, the nurse's INITIAL priority is to

• A. Restrict the client to the room
• B. Place the client under one-to-one supervision
• C. Restore the client's self-control and prevent further loss of control
• D. Clear the immediate area of other clients to prevent harm

Correct answer: C

Rationale: When dealing with a physically assaultive client, the initial priority is to focus on restoring the client's self-control and preventing further escalation. Restricting the client to the room (choice A) may escalate the situation and is not the initial priority. Placing the client under one-to-one supervision (choice B) is important but comes after ensuring the client's self-control. Clearing the immediate area of other clients (choice D) is essential for safety but is not the initial priority when compared to restoring the client's self-control.

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