Nursing Elites

1. A nurse is assessing a client who is being admitted from the PACU following an abdominal hysterectomy. Which of the following assessments is the nurse's priority?

• A. Urinary output
• B. Pain level
• C. Oxygen saturation
• D. Abdominal dressing

Correct answer: C

Rationale: The correct answer is C: Oxygen saturation. Following abdominal surgery, the priority assessment is to ensure adequate oxygenation. Monitoring oxygen saturation is crucial as the client may be at risk of respiratory complications due to the effects of anesthesia, pain medications, and the surgical procedure itself. Assessing urinary output is important for monitoring kidney function but is not the priority immediately postoperatively. Pain level assessment is essential for the client's comfort but does not take precedence over ensuring oxygen saturation. Checking the abdominal dressing is important for wound assessment, but ensuring adequate oxygenation is the priority in the immediate postoperative period.

2. A nurse is observing a patient's use of a walker. Which observation indicates a need for further teaching?

• A. The patient advances the walker too far ahead.
• B. The patient uses the walker to assist in standing.
• C. The patient maintains their balance while using the walker.
• D. The patient walks with their back hunched over.

Correct answer: A

Rationale: The correct answer is A because advancing the walker too far ahead increases the risk of falls, indicating a need for further teaching. Choice B is correct as using the walker to assist in standing is a proper use. Choice C is correct as maintaining balance while using the walker shows proper technique. Choice D is incorrect as walking with the back hunched over is a posture issue, not directly related to walker use.

3. A nurse enters a client's room and finds the client pulseless. The client's living will requests no resuscitation be performed, but the provider has not written the prescription. Which of the following actions should the nurse take?

• A. Administer emergency medications without performing CPR
• B. Begin CPR
• C. Call the provider for a do-not-resuscitate (DNR) order
• D. Respect the client's wishes, and do not attempt CPR

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to begin CPR. In the absence of a written DNR order by the provider, the nurse is ethically and legally obligated to initiate CPR to attempt to save the client's life. Administering emergency medications without CPR (Choice A) may not address the immediate need for life-saving measures. Calling the provider for a DNR order (Choice C) may cause a delay in providing necessary resuscitative measures. Respecting the client's wishes and not attempting CPR (Choice D) goes against the nurse's duty to provide immediate life-saving interventions in the absence of a DNR order.

4. What is a primary goal when managing a client with generalized anxiety disorder (GAD)?

• A. Encourage the client to engage in regular physical exercise
• B. Help the client avoid anxiety triggers through behavioral therapy
• C. Encourage the client to express feelings openly
• D. Teach relaxation techniques to help manage anxiety

Correct answer: D

Rationale: When managing a client with generalized anxiety disorder (GAD), a primary goal is to teach relaxation techniques to help manage anxiety. Relaxation techniques such as deep breathing, progressive muscle relaxation, and mindfulness can be effective in reducing anxiety symptoms. Encouraging the client to engage in regular physical exercise (Choice A) can be beneficial but teaching relaxation techniques is more specific to managing anxiety. Avoiding anxiety triggers through behavioral therapy (Choice B) may be part of the treatment plan but teaching relaxation techniques is more directly aimed at managing anxiety. While encouraging the client to express feelings openly (Choice C) can be important for overall emotional well-being, teaching relaxation techniques is more focused on addressing the symptoms of anxiety.

5. A community health nurse is providing an educational session on childhood poisoning at a local school. What should the nurse advise as the first action if poisoning occurs?

• A. Call the poison control center
• B. Bring the child to the emergency department (ED)
• C. Induce vomiting
• D. Call an ambulance

Correct answer: A

Rationale: In the event of poisoning, the recommended first action is to call the poison control center. Poison control specialists can provide immediate guidance on how to manage the situation effectively. Bringing the child to the emergency department (Choice B) may be necessary depending on the severity of the poisoning, but contacting poison control first is crucial for appropriate and timely intervention. Inducing vomiting (Choice C) is not advised in all cases of poisoning and should only be done under the guidance of healthcare professionals. Calling an ambulance (Choice D) may be necessary in some severe cases, but the initial step should be to contact poison control for expert advice.

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