Nursing Elites

1. A nurse is caring for a client who is postpartum and reports perineal pain. Which intervention should the nurse implement?

• A. Administer analgesics as prescribed.
• B. Apply a warm compress to the perineum.
• C. Encourage the client to ambulate frequently.
• D. Position the client with the head elevated.

Correct answer: A

Rationale: Administering analgesics as prescribed is the appropriate intervention for managing perineal pain in a postpartum client. Analgesics help to alleviate discomfort and promote the client's recovery. Applying a warm compress (choice B) may provide some relief, but it does not address the pain as effectively as analgesics. Encouraging ambulation (choice C) and positioning the client with the head elevated (choice D) are not directly related to addressing perineal pain.

2. A healthcare professional is preparing to administer an IV bolus of morphine to a client. Which of the following actions should the healthcare professional take first?

• A. Check the client's respiratory rate.
• B. Administer naloxone.
• C. Check the client's pain level.
• D. Assess the client's blood pressure.

Correct answer: A

Rationale: Correct Answer: Checking the client's respiratory rate is the priority before administering morphine because morphine can depress respiration. This action helps the healthcare professional assess the client's baseline respiratory status and detect any potential respiratory depression that may be exacerbated by morphine. Choice B, administering naloxone, is incorrect because naloxone is used as an antidote for opioid overdose and not routinely administered before giving morphine. Choice C, checking the client's pain level, is important but not the first action to take before administering morphine. Choice D, assessing the client's blood pressure, is also important but not the initial priority compared to evaluating respiratory status when preparing to administer morphine.

3. A client has a new prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include?

• A. Take the medication with a full glass of water.
• B. Take the medication with food to prevent stomach upset.
• C. Take one tablet every 5 minutes, up to three doses, for chest pain.
• D. Swallow the tablet whole for the best effect.

Correct answer: C

Rationale: The correct instruction for a client with a new prescription for nitroglycerin sublingual tablets is to take one tablet every 5 minutes, up to three doses, for chest pain. This dosing regimen helps relieve chest pain associated with angina by promoting vasodilation. Option A is incorrect as nitroglycerin sublingual tablets should be placed under the tongue, not swallowed with water. Option B is incorrect because taking nitroglycerin with food may decrease its effectiveness. Option D is incorrect because nitroglycerin sublingual tablets are meant to be dissolved under the tongue, not swallowed whole.

4. A client has a chest tube connected to a water-seal drainage system. Which of the following actions should be taken?

• A. Clamp the chest tube during ambulation
• B. Keep the collection chamber below the level of the chest
• C. Add sterile water to the water-seal chamber
• D. Empty the collection chamber every 12 hours

Correct answer: C

Rationale: The correct action for the nurse to take when caring for a client with a chest tube connected to a water-seal drainage system is to add sterile water to the water-seal chamber. This is necessary to maintain the correct water level for proper chest tube function. Clamping the chest tube during ambulation (Choice A) is incorrect as it can lead to complications by obstructing drainage. Keeping the collection chamber below the level of the chest (Choice B) is incorrect because it should be kept below the chest to facilitate drainage. Emptying the collection chamber every 12 hours (Choice D) is incorrect as it should be emptied whenever it reaches the fill line or as per facility policy, not on a fixed time schedule.

5. A nurse is assessing a client who is at 34 weeks of gestation and has gestational hypertension. Which of the following findings should the nurse report to the provider?

• A. Blood pressure of 140/90 mm Hg
• B. Fasting blood glucose of 120 mg/dL
• C. Urinary output of 40 mL/hr
• D. Weight gain of 2.3 kg (5 lb) in 1 week

Correct answer: D

Rationale: A weight gain of 2.3 kg (5 lb) in 1 week can indicate worsening gestational hypertension and should be reported to the provider. Sudden weight gain in a client with gestational hypertension can be a sign of fluid retention, which could worsen the hypertension and lead to complications like preeclampsia. The other options, blood pressure of 140/90 mm Hg, fasting blood glucose of 120 mg/dL, and urinary output of 40 mL/hr, are within normal limits for a client with gestational hypertension and do not pose an immediate concern that requires reporting to the provider.

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