Nursing Elites

1. A client is admitted with a diagnosis of fluid volume excess. Which intervention should the nurse include in the client's plan of care?

• A. Encourage increased fluid intake.
• B. Place the client in a high Fowler's position.
• C. Measure the client's intake and output.
• D. Restrict dietary sodium intake.

Correct answer: D

Rationale: Restricting dietary sodium intake (D) is the most critical intervention for a client with fluid volume excess to prevent further fluid retention. Encouraging increased fluid intake (A) would exacerbate the issue by adding more fluid to the body. Placing the client in a high Fowler's position (B) is more relevant for respiratory issues than fluid volume excess. While measuring intake and output (C) is important for assessing fluid balance, restricting sodium intake is the priority as it helps manage fluid levels more effectively by reducing fluid retention.

2. When a student nurse is caught taking a copy of a client's medication administration record to help a friend prepare for the next day's clinical, what should the nurse respond first?

• A. Ask the nursing supervisor to meet with the student.
• B. Notify the student's clinical instructor of the situation.
• C. Ask the student if permission was obtained from the client.
• D. Explain that the records are hospital property and may not be removed.

Correct answer: D

Rationale: The correct response when a student nurse is caught taking a copy of a client's medication administration record is to explain that the records are hospital property and cannot be removed. It is essential to educate the student about the confidentiality and security of patient information, emphasizing that even with the client's consent, such actions are unacceptable. Option A is not the immediate action needed, as addressing the student directly should come first. Option B involves notifying another party before addressing the student directly. Option C is incorrect because even if the client gave permission, patient records are confidential and cannot be shared without authorization.

3. The nurse is preparing to administer 2 units of packed red blood cells (PRBCs) to a client. Which action should the nurse implement to ensure the client’s safety?

• A. Obtain informed consent from the client for the PRBC transfusion
• B. Review the client’s medical history for a history of transfusion reactions
• C. Assess the client’s baseline vital signs before starting the transfusion
• D. Verify the blood type and crossmatch with another licensed nurse

Correct answer: D

Rationale: Verifying the blood type and crossmatch with another licensed nurse is crucial to prevent transfusion reactions and ensure the client's safety. This step helps confirm that the correct blood type is being transfused to the client, reducing the risk of adverse reactions and promoting safe care. Obtaining informed consent (Choice A) is important but not directly related to ensuring the safety of the transfusion. Reviewing the client's medical history for transfusion reactions (Choice B) is relevant but not as crucial as verifying the blood type and crossmatching. Assessing baseline vital signs (Choice C) is a routine practice before transfusion but ensuring the correct blood type is a higher priority.

4. A client with a diagnosis of asthma is receiving albuterol (Proventil) via a metered-dose inhaler (MDI). Which assessment finding indicates that the medication is effective?

• A. Increased oxygen saturation.
• B. Decreased respiratory rate.
• C. Absence of audible wheezing.
• D. Improved exercise tolerance.

Correct answer: A

Rationale: Increased oxygen saturation (A) is the most direct indicator of the effectiveness of albuterol (Proventil) in improving breathing. Oxygen saturation reflects the amount of oxygen in the blood, showing that the albuterol is helping with air exchange in the lungs. While decreased respiratory rate (B), absence of audible wheezing (C), and improved exercise tolerance (D) are positive outcomes, they are secondary to oxygen saturation. Oxygen saturation directly reflects the improvement in the client's respiratory status and the effectiveness of the medication.

5. A client with a history of coronary artery disease (CAD) is admitted with chest pain. Which intervention should the nurse implement first?

• A. Administer sublingual nitroglycerin
• B. Obtain a 12-lead electrocardiogram (ECG)
• C. Apply oxygen via nasal cannula
• D. Initiate continuous cardiac monitoring

Correct answer: C

Rationale: In a client with a history of coronary artery disease (CAD) experiencing chest pain, the priority intervention for the nurse to implement first is to apply oxygen via nasal cannula. Oxygenation is crucial to ensure adequate oxygen supply to the tissues and the heart. This intervention takes precedence over administering sublingual nitroglycerin, obtaining an ECG, or initiating continuous cardiac monitoring. While these interventions are important, ensuring adequate oxygenation is the initial priority in the management of a client with chest pain.

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