Nursing Elites

1. A client has developed a pulmonary embolism. Which of the following interventions should the nurse implement first?

• A. Administer oxygen
• B. Prepare the client for a thoracentesis
• C. Elevate the client’s lower extremities
• D. Administer anticoagulant therapy

Correct answer: A

Rationale: Administering oxygen is the priority intervention for a client with a pulmonary embolism. Pulmonary embolism can lead to impaired gas exchange, causing hypoxemia. Administering oxygen helps to maintain adequate oxygenation levels. Thoracentesis is not indicated for a pulmonary embolism, as it is a procedure to remove fluid or air from the pleural space, not a treatment for embolism. Elevating the client's lower extremities is not a priority in the management of a pulmonary embolism. Administering anticoagulant therapy is important in the treatment of pulmonary embolism to prevent further clot formation, but it is not the first intervention. Oxygen administration takes precedence to address the immediate oxygenation needs of the client.

2. A nurse is administering a blood transfusion to a client and suspects that the client is having an adverse reaction to the blood. Which of the following actions should the nurse take first?

• A. Maintain IV access
• B. Obtain the client’s vital signs
• C. Contact the provider
• D. Stop the transfusion

Correct answer: D

Rationale: The correct answer is to stop the transfusion. When a nurse suspects an adverse reaction to a blood transfusion, the priority is to stop the infusion immediately to prevent further harm to the client. Maintaining IV access and obtaining vital signs can be important steps but should come after stopping the transfusion to ensure the client's safety. Contacting the provider is necessary but not the first action to take in this situation. Therefore, the nurse should prioritize stopping the transfusion to address the potential adverse reaction.

3. A nurse is reviewing a laboratory report for a client who is at 33 weeks of gestation and has preeclampsia. Which of the following laboratory results should the nurse report to the provider?

• A. BUN 35 mg/dL
• B. Hgb 15 g/dL
• C. Bilirubin 0.6 mg/dL
• D. Hct 37%

Correct answer: A

Rationale: A BUN of 35 mg/dL indicates potential kidney impairment, which is a concern in preeclampsia due to compromised renal function. This finding warrants further evaluation by the provider. High BUN levels may suggest reduced kidney function, a common complication associated with preeclampsia. Hgb, Bilirubin, and Hct levels are within normal ranges and are not directly indicative of kidney impairment or preeclampsia in this scenario. Therefore, the nurse should report the elevated BUN level to the healthcare provider for prompt management and monitoring.

4. A nurse is assessing four clients for fluid balance. Which of the following clients is exhibiting manifestations of dehydration?

• A. A client who has a urine specific gravity of 1.010.
• B. A client who has a weight gain of 2.2 kg (2 lb) in 24 hr.
• C. A client who has a hematocrit of 45%.
• D. A client who has a temperature of 39°C (102°F).

Correct answer: D

Rationale: The correct answer is D because an elevated temperature is a common manifestation of dehydration. Choices A, B, and C are not indicative of dehydration. A urine specific gravity of 1.010 is within normal range, weight gain suggests fluid overload, and a hematocrit of 45% is also within normal limits and not specifically related to dehydration.

5. A client who has been prescribed oral contraception receives education from a nurse. Which of the following client statements indicates a need for further education?

• A. If I miss one pill, I'll take it as soon as possible
• B. If I miss two pills, I'll double up for two days
• C. If I miss three pills, I'll double up each day until back on schedule
• D. I'll use an alternative form of contraception if I miss more than two pills

Correct answer: C

Rationale: The correct course of action after missing oral contraceptive pills depends on how many pills are missed. If three pills are missed, the client should not 'double up' but rather follow the manufacturer's instructions and use an alternative form of contraception until the next cycle. Taking too many pills at once increases the risk of side effects without restoring contraceptive protection. Choices A, B, and D demonstrate understanding of the correct actions to take after missing a pill or two, emphasizing the importance of not doubling up but following specific guidelines to maintain effectiveness and safety.

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