Nursing Elites

1. A client receives the influenza vaccine in a clinic. Within 15 minutes after the immunization, the client complains of itchy and watery eyes, increased anxiety, and difficulty breathing. What should be the first action in the sequence of care for this client?

• A. Maintain the airway
• B. Administer epinephrine 1:1000 as ordered
• C. Monitor for hypotension with shock
• D. Administer diphenhydramine as ordered

Correct answer: B

Rationale: In the scenario described, the client is experiencing symptoms of an anaphylactic reaction, a severe allergic response. The priority action in an anaphylactic reaction is to administer epinephrine. Epinephrine helps counteract the severe allergic response, improves breathing difficulties, and maintains airway and circulation. Administering epinephrine takes precedence to stabilize the client's condition. Options A, C, and D may be necessary in the management of anaphylaxis, but the immediate priority is to administer epinephrine to address the life-threatening symptoms.

2. 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.

3. During a staff meeting, a nurse is discussing the purpose of regulatory agencies. Which of the following tasks should the nurse identify as the responsibility of state licensing boards?

• A. Monitoring evidence-based practice for clients with specific diagnoses.
• B. Ensuring that health care providers comply with regulations.
• C. Setting quality standards for accrediting health care facilities.
• D. Determining the safety of medications for administration to clients.

Correct answer: B

Rationale: State licensing boards are primarily responsible for ensuring that health care providers comply with regulations. This includes overseeing licensure requirements, investigating complaints, and enforcing disciplinary actions. Monitoring evidence-based practice for clients with specific diagnoses is typically within the domain of professional organizations or healthcare institutions. Setting quality standards for accrediting health care facilities is usually the role of accrediting bodies such as The Joint Commission. Lastly, determining the safety of medications for administration to clients falls under the purview of regulatory agencies like the Food and Drug Administration (FDA).

4. A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take?

• A. Check the catheter to see whether it is patent.
• B. Reassure the client that it is not possible for them to urinate.
• C. Re-catheterize the bladder with a larger-gauge catheter.
• D. Collect a urine specimen for analysis.

Correct answer: A

Rationale: When a client with an indwelling catheter reports a need to urinate, the nurse's initial action should be to check the catheter for patency. This is crucial to ensure that the catheter is not blocked, twisted, or kinked, which could lead to urinary retention. Reassuring the client without assessing the catheter could delay necessary interventions. Re-catheterizing the bladder with a larger-gauge catheter should not be the first step unless catheter patency is confirmed as an issue. Collecting a urine specimen for analysis is important but not the immediate priority when the client reports a need to urinate.

5. 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.

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