Nursing Elites

1. A nurse is caring for a client who has a history of alcohol use disorder and is experiencing withdrawal. Which of the following actions should the nurse take?

• A. Administer naloxone
• B. Administer diazepam
• C. Encourage oral fluid intake
• D. Administer magnesium sulfate

Correct answer: B

Rationale: The correct action for the nurse to take when caring for a client with alcohol use disorder experiencing withdrawal is to administer diazepam. Diazepam is a benzodiazepine commonly used to manage withdrawal symptoms in these clients by reducing anxiety, tremors, and the risk of seizures. Administering naloxone (Choice A) is used for opioid overdose, not alcohol withdrawal. Encouraging oral fluid intake (Choice C) is generally beneficial but not a specific intervention for alcohol withdrawal. Administering magnesium sulfate (Choice D) is not indicated for alcohol withdrawal but may be used for other conditions like preeclampsia or eclampsia.

2. A nurse is assessing a client who has just returned from surgery and is experiencing acute pain. Which of the following findings should the nurse expect?

• A. Bradycardia.
• B. Hypotension.
• C. Diaphoresis.
• D. Hyperactive bowel sounds.

Correct answer: C

Rationale: The correct answer is C: Diaphoresis. Diaphoresis, which is excessive sweating, is a common response to acute pain due to increased sympathetic nervous system activity. Options A and B, Bradycardia and Hypotension, are unlikely findings in a client experiencing acute pain as pain usually triggers an increase in heart rate (tachycardia) and blood pressure. Option D, Hyperactive bowel sounds, is not typically associated with acute pain.

3. A nurse is caring for an infant who has a prescription for continuous pulse oximetry. Which of the following is an appropriate action for the nurse to take?

• A. Place the infant under a radiant warmer
• B. Move the probe site every 3 hours
• C. Heat the skin one minute prior to placing the probe
• D. Place a sensor on the index finger

Correct answer: B

Rationale: The correct answer is to move the probe site every 3 hours. This action helps prevent skin breakdown and ensures accurate readings. Placing the infant under a radiant warmer (Choice A) is not necessary for pulse oximetry monitoring. Heating the skin before placing the probe (Choice C) can potentially cause burns in infants. Placing a sensor on the index finger (Choice D) is not the standard practice for continuous pulse oximetry in infants.

4. A nurse is assessing a client who has just received an opioid medication. Which of the following findings should the nurse monitor first?

• A. Constipation.
• B. Drowsiness.
• C. Orthostatic hypotension.
• D. Respiratory depression.

Correct answer: D

Rationale: When a client receives an opioid medication, the nurse should first monitor for respiratory depression as it is a life-threatening adverse effect associated with opioids. This can lead to inadequate ventilation and hypoxia, requiring immediate intervention. Constipation, drowsiness, and orthostatic hypotension are also common side effects of opioids but are not as immediately life-threatening as respiratory depression.

5. A nurse is assessing a client who has a peripherally inserted central catheter (PICC). Which of the following findings should the nurse report to the provider?

• A. Redness at the insertion site.
• B. Swelling of the arm above the insertion site.
• C. A bruised area around the insertion site.
• D. A temperature of 37.2°C (99°F).

Correct answer: B

Rationale: Swelling of the arm above the insertion site is concerning as it can indicate complications like thrombosis, which require immediate attention. Redness at the insertion site is common and expected in the initial stages. A bruised area around the insertion site may result from the insertion procedure and is usually not alarming unless it worsens or becomes larger. A temperature of 37.2°C (99°F) is within the normal range and is not directly related to PICC complications.

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