Nursing Elites

1. A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the LPN/LVN implement first?

• A. Assist the ambulating client back to the bed.
• B. Encourage the client to ambulate to resolve pneumonia.
• C. Obtain a prescription for portable oxygen while ambulating.
• D. Move the oximetry probe from the finger to the earlobe.

Correct answer: A

Rationale: The correct intervention is to assist the client back to bed. A decrease in oxygen saturation while ambulating indicates hypoxemia, and the immediate priority is to stabilize oxygen levels. Returning the client to bed allows for rest and decreased oxygen demand, potentially preventing further desaturation. Encouraging continued ambulation (Choice B) may worsen the hypoxemia by increasing oxygen demand. Obtaining portable oxygen (Choice C) is essential but should not delay addressing the low oxygen saturation. Moving the oximetry probe (Choice D) may not address the underlying cause of decreased oxygen saturation and should not be the first intervention.

2. While caring for an older adult client who is violent and attempting to disconnect her IV lines, the provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints?

• A. Remove the restraints one at a time
• B. Secure the restraints tightly to prevent movement
• C. Check the restraints every hour
• D. Use leather restraints for additional security

Correct answer: A

Rationale: Removing restraints one at a time is the correct action to take when caring for a client in soft wrist restraints. This approach ensures safety and comfort while still maintaining the necessary restrictions. Choice B is incorrect as securing the restraints tightly can lead to circulatory issues and discomfort. Choice C of checking the restraints every hour is a reasonable action, but it is not the priority when compared to the correct choice of removing the restraints one at a time. Choice D of using leather restraints for additional security is unnecessary and may be more restrictive and uncomfortable for the client.

3. A nurse on a surgical unit is receiving a client who had abdominal surgery from the postanesthesia care unit. Which of the following assessments should the nurse make first?

• A. Airway
• B. Blood pressure
• C. Surgical site
• D. Level of consciousness

Correct answer: A

Rationale: The correct answer is to assess the airway first. Ensuring a clear and patent airway is crucial to maintaining adequate oxygenation and ventilation post-surgery. Assessing the airway takes precedence over other assessments as a compromised airway can lead to hypoxia and respiratory distress. Checking blood pressure, the surgical site, or level of consciousness are important but are secondary to ensuring the airway is clear and the client can breathe effectively.

4. A nurse prepares to admit a client who is immediately postoperative to the unit following abdominal surgery. When transferring the client from the gurney to the bed, what should the nurse do?

• A. Lock the wheels on the bed and gurney
• B. Adjust the bed height
• C. Use a slide sheet
• D. Ask for assistance from another nurse

Correct answer: A

Rationale: The correct action for the nurse to take when transferring a postoperative client from the gurney to the bed is to lock the wheels on both the bed and the gurney. Locking the wheels ensures stability and prevents accidents during the transfer. Adjusting the bed height may be necessary for comfort but is not the primary concern during the transfer process. Using a slide sheet may be helpful in repositioning the client once on the bed but is not essential for the initial transfer. Asking for assistance from another nurse is always a good practice, but the immediate action to ensure safety during the transfer is to lock the wheels.

5. A nurse at a provider’s office is discussing routine screenings with a 45-year-old female client who has no specific family history of cancer or diabetes mellitus. Which of the following client statements indicates that the client understands how to proceed?

• A. “So I don’t need the colon cancer screening for another 2 or 3 years.”
• B. “For now, I should continue to have a mammogram each year.”
• C. “Because the doctor just performed a Pap smear, I’ll return next year for another one.”
• D. “I had my glucose test last year, so I won’t need it again for 4 years.”

Correct answer: B

Rationale: The correct answer is B. Mammograms are recommended annually for women starting at age 40 or 45. This statement aligns with current guidelines for breast cancer screening in women without specific risk factors. Choice A is incorrect because colon cancer screenings are typically recommended at different intervals. Choice C is incorrect as Pap smears are usually done every 3-5 years based on age and risk factors. Choice D is incorrect because glucose testing is usually recommended more frequently, especially for individuals at risk for diabetes mellitus.

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