Nursing Elites

1. A client with chronic heart failure is admitted with shortness of breath and a new onset of confusion. Which intervention should the nurse implement first?

• A. Obtain a neurological assessment.
• B. Administer oxygen therapy.
• C. Monitor the client's urine output.
• D. Obtain an electrocardiogram (ECG).

Correct answer: A

Rationale: The correct answer is to obtain a neurological assessment. In a client with chronic heart failure presenting with confusion, the priority is to assess neurological status to rule out potential causes such as hypoxia or other complications. Administering oxygen therapy (Choice B) is important but assessing the neurological status takes precedence in this scenario. Monitoring urine output (Choice C) and obtaining an ECG (Choice D) may be necessary but are not the initial priority when a client presents with confusion alongside shortness of breath.

2. A client with rapid respirations and audible rhonchi is admitted to the intensive care unit because of a pulmonary embolism (PE). Low-flow oxygen by nasal cannula and weight-based heparin protocol are initiated. Which intervention is most important for the nurse to include in this client's plan of care?

• A. Evaluate blood clotting factors daily.
• B. Encourage incentive spirometry use.
• C. Administer pain medication as needed.
• D. Monitor for signs of bleeding.

Correct answer: A

Rationale: Evaluating blood clotting factors daily is crucial when a client is on heparin therapy to monitor for potential complications such as bleeding or clotting issues. This monitoring helps ensure that the heparin dose is within the therapeutic range and reduces the risk of bleeding or clotting complications. Encouraging incentive spirometry use is beneficial for preventing atelectasis and improving lung function, but in this scenario, monitoring blood clotting factors takes precedence. Administering pain medication as needed is important for the client's comfort but is not the priority in managing a pulmonary embolism. Monitoring for signs of bleeding is important due to heparin therapy, but evaluating blood clotting factors provides more specific information on the client's response to treatment.

3. The nurse observes an unlicensed assistive personnel (UAP) using an alcohol-based gel hand cleaner before performing catheter care. The UAP rubs both hands thoroughly for 2 minutes while standing at the bedside. What action should the nurse take?

• A. Encourage the UAP to remain in the client's room until the hand rub is completed.
• B. Explain that the hand rub can be completed in less than 2 minutes.
• C. Inform the UAP that handwashing helps to promote better asepsis.
• D. Determine why the UAP was not wearing gloves in the client's room.

Correct answer: B

Rationale: The correct answer is B. Alcohol-based hand rubs are effective with a shorter rub time, typically around 20-30 seconds. Standing at the bedside for 2 minutes to rub hands thoroughly is unnecessary and can lead to wastage of resources. It's essential for the nurse to educate the UAP on proper hand hygiene techniques to ensure efficient and effective infection control practices. Choices A, C, and D are incorrect because encouraging the UAP to remain in the client's room, discussing handwashing instead of hand rubs, and questioning glove use are not the most appropriate actions in this scenario.

4. Which assessment finding requires immediate intervention for a client receiving enteral feedings via a nasogastric tube?

• A. Auscultate the client's lungs for breath sounds
• B. Check the client's blood glucose level
• C. Monitor the client's bowel sounds
• D. Elevate the head of the bed to 45 degrees

Correct answer: D

Rationale: Elevating the head of the bed to 45 degrees is crucial for clients receiving enteral feedings via a nasogastric tube to prevent aspiration. Aspiration can lead to serious complications such as pneumonia. Auscultating the client's lungs for breath sounds (choice A) is important but not as urgent as preventing aspiration. Checking the client's blood glucose level (choice B) and monitoring bowel sounds (choice C) are also essential aspects of care for a client receiving enteral feedings, but they do not take precedence over preventing aspiration.

5. The nurse is caring for a client with a chest tube following a pneumothorax. Which finding requires immediate intervention?

• A. Oxygen saturation of 94%
• B. Crepitus around the insertion site
• C. Subcutaneous emphysema
• D. Drainage of 50 ml per hour

Correct answer: C

Rationale: Subcutaneous emphysema is the most critical finding requiring immediate intervention in a client with a chest tube following a pneumothorax. It may indicate a pneumothorax recurrence or air leak, which can lead to respiratory compromise. Oxygen saturation of 94% is slightly low but may not require immediate intervention. Crepitus around the insertion site can be a normal finding post-procedure. Drainage of 50 ml per hour is within the expected range for a chest tube output and does not indicate an immediate concern.

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