Nursing Elites

1. When asking an unlicensed assistive personnel (UAP) to assist a 69-year-old surgical client to ambulate for the first time, which statement by the nurse is appropriate?

• A. Have the client sit on the side of the bed for at least 2 minutes before helping him stand.
• B. If the client is dizzy on standing, ask him to take some deep breaths.
• C. Assist the client to the bathroom at least twice on this shift.
• D. After you assist him to the chair, let me know how he feels.

Correct answer: A

Rationale: The correct answer is A. Allowing the client to sit on the side of the bed before standing helps prevent dizziness and falls, especially during their first ambulation post-surgery. Choice B is incorrect because asking the client to take deep breaths when feeling dizzy may not address the underlying cause of the dizziness. Choice C is incorrect as it is unrelated to the task of assisting the client to ambulate for the first time. Choice D is incorrect because knowing how the client feels after sitting in the chair does not address the important step of assisting the client to stand up for the first time.

2. A client asks the nurse to call the police and states: 'I need to report that I am being abused by a nurse.' The nurse should first

• A. Focus on reality orientation to place and person
• B. Assist with the report of the client's complaint to the police
• C. Obtain more details of the client's claim of abuse
• D. Document the statement in the client's chart with a report to the manager

Correct answer: C

Rationale: The correct initial action for the nurse is to obtain more details about the client's claim of abuse. This will help the nurse better understand the situation before proceeding with any further actions. Option A is incorrect as reality orientation is not the priority in this situation. Option B is premature as more details are needed first. Option D is not the immediate step as gathering information should come before documentation and reporting.

3. The healthcare provider is caring for a client with severe anemia. Which assessment finding requires immediate intervention?

• A. Pale skin
• B. Increased heart rate
• C. Shortness of breath
• D. Fatigue

Correct answer: C

Rationale: Shortness of breath is a critical sign in severe anemia as it indicates inadequate oxygenation, which can be life-threatening. Immediate intervention is necessary to address this condition. Pale skin (choice A) is a common finding in anemia but not as urgent as shortness of breath. Increased heart rate (choice B) is a compensatory mechanism in anemia to maintain oxygen delivery and is important but not as urgent as addressing inadequate oxygenation. Fatigue (choice D) is a common symptom in anemia but does not indicate an immediate life-threatening situation like shortness of breath does.

4. A client with asthma is prescribed an inhaled corticosteroid. What teaching should the nurse provide?

• A. Rinse the mouth with water after using the inhaler.
• B. Take the medication only during asthma attacks.
• C. Avoid using the inhaler before exercise.
• D. Clean the inhaler with hot water after each use.

Correct answer: A

Rationale: The correct teaching the nurse should provide to a client prescribed an inhaled corticosteroid is to rinse the mouth with water after using the inhaler. This helps prevent oral fungal infections, a common side effect of inhaled corticosteroids. Choice B is incorrect because inhaled corticosteroids are usually used regularly, not just during asthma attacks. Choice C is incorrect as using the inhaler before exercise can actually help prevent exercise-induced bronchospasm. Choice D is incorrect because cleaning the inhaler with hot water after each use is not necessary and may damage the device.

5. The nurse is caring for a client with an exacerbation of chronic obstructive pulmonary disease (COPD). Which intervention is most important to promote effective breathing?

• A. Encourage diaphragmatic breathing
• B. Increase the client's oxygen flow rate
• C. Have the client perform range of motion exercises
• D. Place the client in a supine position

Correct answer: A

Rationale: Encouraging diaphragmatic breathing is crucial in clients with COPD as it helps improve lung expansion and oxygen exchange, promoting more effective breathing. This intervention aids in reducing dyspnea and enhancing ventilation. Increasing the client's oxygen flow rate may not be appropriate and can potentially worsen hypercapnia in individuals with COPD. Performing range of motion exercises and placing the client in a supine position do not directly address the breathing difficulties associated with COPD exacerbation.

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