Nursing Elites

1. A healthcare provider is assessing a client who has been using beclomethasone for 2 weeks to manage her asthma. What is the priority to report to the provider?

• A. Sore throat
• B. Cough
• C. Chest tightness
• D. Bronchospasms

Correct answer: D

Rationale: The correct answer is D: Bronchospasms. Bronchospasms can indicate worsening asthma and are considered a severe side effect that requires immediate attention. While sore throat, cough, and chest tightness are also possible side effects of beclomethasone, bronchospasms are of higher concern due to their association with significant respiratory distress and potential exacerbation of asthma symptoms.

2. A nurse is caring for a patient who is postoperative day 1 following abdominal surgery. What is the nurse's priority action to prevent complications?

• A. Encourage the patient to perform incentive spirometry.
• B. Assist the patient in ambulating around the unit.
• C. Reposition the patient every 2 hours.
• D. Administer pain medication as prescribed.

Correct answer: A

Rationale: The correct answer is to encourage the patient to perform incentive spirometry. Incentive spirometry helps prevent respiratory complications, such as atelectasis, by promoting deep breathing and optimal lung expansion. Ambulating, repositioning, and administering pain medication are important interventions but do not take precedence over preventing respiratory complications in the immediate postoperative period.

3. Which intervention will best help a patient with chronic pain maintain mobility?

• A. Provide the patient with opioids to control pain.
• B. Encourage stretching exercises to improve flexibility.
• C. Teach the patient to use assistive devices like a cane.
• D. Recommend complete bed rest until the pain subsides.

Correct answer: B

Rationale: Encouraging stretching exercises is the most appropriate nursing intervention to help a patient with chronic pain maintain mobility. Stretching exercises can improve flexibility, prevent stiffness, and promote better range of motion in patients with chronic pain. Providing opioids (Choice A) may help control pain but does not directly address mobility. Teaching the patient to use assistive devices (Choice C) may be beneficial but does not focus on improving mobility directly. Recommending complete bed rest (Choice D) can lead to deconditioning and further loss of mobility, which is not recommended for chronic pain management.

4. A nurse is assessing a postoperative patient for signs of infection. Which finding is most concerning?

• A. Mild redness at the incision site.
• B. Increased drainage from the surgical site.
• C. Fever of 101°F.
• D. Normal white blood cell count.

Correct answer: C

Rationale: A fever of 101°F is the most concerning finding when assessing a postoperative patient for signs of infection. Fever can indicate an inflammatory response to an infection, and in a postoperative patient, it can signal a surgical site infection or a systemic infection. Prompt attention is necessary to prevent complications such as sepsis. Mild redness at the incision site and increased drainage can be expected in the early postoperative period due to the normal healing process. A normal white blood cell count does not rule out infection as it can be influenced by various factors, and some infections may not initially cause a rise in white blood cells.

5. What is the most important nursing action when caring for a patient with a central venous catheter (CVC)?

• A. Monitor the patient's blood pressure regularly.
• B. Change the CVC dressing every 72 hours.
• C. Flush the CVC with normal saline every shift.
• D. Avoid using the CVC for blood draws.

Correct answer: B

Rationale: The most important nursing action when caring for a patient with a central venous catheter (CVC) is to change the CVC dressing every 72 hours. This practice reduces the risk of infection and ensures the catheter remains secure. Monitoring the patient's blood pressure regularly is important but not the most crucial action when managing a CVC. Flushing the CVC with normal saline is essential but not the most important action. Avoiding using the CVC for blood draws is a good practice, but it is not the most critical nursing action in this scenario.

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