Nursing Elites

1. A nurse is caring for a client who is 12 hr postpartum and has a third-degree perineal laceration. The client reports not having a bowel movement for 4 days. Which of the following medications should the nurse administer?

• A. Bisacodyl 10 mg rectal suppository.
• B. Magnesium hydroxide 30 ml PO.
• C. Famotidine 20 mg PO.
• D. Loperamide 4 mg PO.

Correct answer: A

Rationale: In this scenario, the nurse should administer Bisacodyl 10 mg rectal suppository. Bisacodyl is a stimulant laxative that promotes bowel movement, which is appropriate for a postpartum client experiencing constipation. Magnesium hydroxide (choice B) is an antacid and not indicated for constipation. Famotidine (choice C) is an H2 receptor antagonist used for reducing stomach acid production, not for constipation. Loperamide (choice D) is an antidiarrheal agent and would worsen constipation in this case.

2. What is the priority nursing action for a patient with respiratory distress?

• A. Administer oxygen
• B. Reposition the patient
• C. Administer bronchodilators
• D. Provide chest physiotherapy

Correct answer: A

Rationale: The priority nursing action for a patient with respiratory distress is to administer oxygen. Oxygen therapy is crucial in improving oxygenation levels and relieving respiratory distress, making it the top priority intervention. Repositioning the patient, administering bronchodilators, or providing chest physiotherapy may be necessary interventions depending on the underlying cause, but ensuring adequate oxygen supply should take precedence in addressing respiratory distress.

3. A nurse is caring for a client who has a history of angina. The client reports chest pain. Which of the following actions should the nurse take?

• A. Administer sublingual nitroglycerin every 5 minutes
• B. Administer aspirin 325 mg
• C. Encourage the client to use deep breathing exercises
• D. Apply oxygen at 2 L/min via nasal cannula

Correct answer: A

Rationale: The correct action for the nurse to take when a client with a history of angina reports chest pain is to administer sublingual nitroglycerin every 5 minutes. Nitroglycerin helps dilate blood vessels, improving blood flow to the heart and relieving chest pain associated with angina. Aspirin is often given during a suspected heart attack, not for immediate relief of angina. Deep breathing exercises may be beneficial for anxiety or respiratory conditions but are not the first-line intervention for angina. Oxygen therapy is not the initial treatment for angina unless the client is hypoxic.

4. A nurse is caring for a client who is 12 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Serosanguineous drainage on the surgical dressing.
• B. Respiratory rate of 16/min.
• C. Heart rate of 90/min.
• D. WBC count of 15,000/mm3.

Correct answer: D

Rationale: A WBC count of 15,000/mm3 is elevated, which may indicate infection, a common concern postoperatively. An elevated WBC count suggests the body is fighting an infection, and prompt reporting to the provider is essential for further evaluation and treatment. Serosanguineous drainage on the surgical dressing is expected in the immediate postoperative period, respiratory rate of 16/min is within the normal range, and a heart rate of 90/min is also within an acceptable range postoperatively. Therefore, these findings do not raise immediate concerns that necessitate reporting to the provider.

5. A nurse is preparing to administer an intermittent enteral feeding to a client who has an NG tube. Which of the following actions should the nurse take?

• A. Heat the feeding to 105°F (40.6°C).
• B. Elevate the head of the bed to 45 degrees.
• C. Flush the tube with 0.9% sodium chloride.
• D. Verify the pH of the gastric aspirate.

Correct answer: D

Rationale: Verifying the pH of the gastric aspirate is the correct action to take before administering an intermittent enteral feeding through an NG tube. This step ensures proper tube placement in the stomach, as the gastric aspirate should have an acidic pH (usually below 5). Heating the feeding solution, elevating the head of the bed, or flushing the tube with saline are not directly related to verifying tube placement and are not the immediate actions needed before administering the feeding.

Similar Questions