Nursing Elites

1. A client who had an intraosseous (IO) cannula placed by the healthcare provider for emergent fluid resuscitation is complaining of severe pain and numbness below the IO site. The skin around the site is pale and edematous. What action should the nurse take first?

• A. Discontinue the IO infusion
• B. Administer an analgesic via the IO site
• C. Elevate the extremity with the IO site
• D. Notify the healthcare provider

Correct answer: A

Rationale: The correct action for the nurse to take first is to discontinue the IO infusion. The client's symptoms of severe pain, numbness, pale skin, and edema below the IO site suggest a complication, such as extravasation or compartment syndrome. By discontinuing the infusion, further harm can be prevented. Administering an analgesic via the IO site or elevating the extremity would not address the underlying issue and could potentially worsen the condition. Notifying the healthcare provider can be done after stopping the infusion to seek further guidance or intervention.

2. The client who is to avoid any weight-bearing on the left leg is using a 3-point crutch gait for ambulation. What is the best action for the nurse to initiate?

• A. Encourage continued use of the 3-point crutch gait by the client
• B. Encourage the client to use a wheelchair for mobility
• C. Instruct the client in the use of a 4-point crutch gait
• D. Instruct the client in the use of a 2-point crutch gait

Correct answer: C

Rationale: In this scenario, the client needs to avoid weight-bearing on the left leg. A 4-point crutch gait involves using both crutches and both legs, making it more appropriate for weight-bearing restrictions. Encouraging the use of a 3-point gait (choice A) would not provide adequate support for the client's condition. While using a wheelchair (choice B) could be an option, instructing the client in a 4-point crutch gait would promote mobility while adhering to weight-bearing restrictions. A 2-point crutch gait (choice D) involves using both crutches and one leg, which is not suitable for avoiding weight-bearing on the left leg.

3. During the administration of albuterol per nebulizer, the client complains of shakiness. The client’s vital signs are heart rate 120 beats/minute, respirations 20 breaths/minute, blood pressure 140/80. What action should the nurse take?

• A. Administer an anxiolytic
• B. Obtain a 12-lead electrocardiogram
• C. Stop the albuterol administration and restart in 30 minutes
• D. Educate the client about the side effects of albuterol

Correct answer: D

Rationale: Shakiness is a known side effect of albuterol, which can often be managed without the need for additional medications. Educating the client about the potential side effects of albuterol, including shakiness, helps them understand what to expect and how to manage these effects. Administering an anxiolytic (Choice A) is not indicated as shakiness related to albuterol is not a sign of anxiety. Obtaining a 12-lead electrocardiogram (Choice B) is not necessary based on the client's presentation of shakiness and vital signs. Stopping the albuterol administration and restarting in 30 minutes (Choice C) may not be necessary since shakiness is a common side effect that can often be managed without interrupting the treatment.

4. A client collapses while showering and is found by the nurse while making rounds. The client is not breathing and does not have a palpable pulse. The nurse obtains the Automated External Defibrillator (AED). What action should the nurse implement next?

• A. Follow the prompts of the AED
• B. Apply the AED pads to the client’s chest
• C. Wipe the client’s chest dry
• D. Move the client from the bathroom

Correct answer: B

Rationale: Applying the AED pads is the immediate next step after obtaining the AED in a cardiac arrest situation. Placing the pads correctly on the client's chest is crucial for the AED to analyze the heart rhythm accurately and deliver a shock if needed. Following the prompts of the AED comes after the pads are in place. Wiping the client's chest dry or moving the client from the bathroom are not priorities at this critical moment and may delay life-saving interventions.

5. The nurse is caring for a laboring 22-year-old primigravida following administration of regional anesthesia. In planning care for this client, what nursing intervention has the highest priority?

• A. Raising the side rails and placing the call bell within reach
• B. Teaching the client how to push to decrease the length of the second stage of labor
• C. Timing and recording uterine contractions
• D. Positioning the client for proper distribution of anesthesia

Correct answer: D

Rationale: The highest priority nursing intervention for a laboring client following administration of regional anesthesia is to position the client for proper distribution of anesthesia. Proper positioning ensures effective pain management during labor, optimizing the effects of the regional anesthesia. While raising the side rails and placing the call bell within reach (choice A) is important for safety, teaching the client how to push (choice B) and timing and recording uterine contractions (choice C) are vital aspects of care but are not the highest priority immediately after administering regional anesthesia.

Similar Questions