Nursing Elites

1. A nurse is caring for a patient with heart failure who has developed pulmonary edema. What is the nurse's priority action?

• A. Administer a diuretic as prescribed.
• B. Place the patient in a high Fowler's position.
• C. Administer oxygen via nasal cannula.
• D. Monitor the patient's lung sounds every 2 hours.

Correct answer: B

Rationale: The correct answer is to place the patient in a high Fowler's position. This position helps improve lung expansion and oxygenation in cases of pulmonary edema by reducing venous return to the heart and enhancing respiratory mechanics. Administering a diuretic (Choice A) can be important but is not the priority over positioning in this situation. Administering oxygen (Choice C) is essential, but the priority action for improving oxygenation is the positioning of the patient. Monitoring lung sounds (Choice D) is crucial for ongoing assessment but is not the priority action when the patient is in distress with pulmonary edema.

2. A nurse manager is asked to select clients for early discharge from the unit following a mass casualty event. Which of the following clients should the nurse manager recommend?

• A. A client awaiting a screening colonoscopy later that day
• B. A client whose discharge was cancelled the prior day because they developed respiratory distress
• C. A client who is 6 hr postoperative following an open cholecystectomy
• D. A client who is prescribed gastric lavage treatments to treat acute aspirin toxicity

Correct answer: A

Rationale: The nurse manager should recommend the client awaiting a screening colonoscopy later that day for early discharge following a mass casualty event. This client is stable and not in immediate need of hospital care. Choices B, C, and D involve clients who require ongoing monitoring and care due to recent developments or treatments, making them unsuitable for early discharge during a mass casualty event.

3. What are the key components of a pain assessment in a postoperative patient?

• A. Checking the effectiveness of pain interventions
• B. Observing for nonverbal signs of pain like grimacing
• C. Assessing the location, duration, and quality of the pain
• D. Asking the patient to rate their pain on a scale of 1-10

Correct answer: A

Rationale: The correct answer is A because in a postoperative patient, it is crucial to evaluate the effectiveness of the pain interventions that have been implemented. While choices B, C, and D are important aspects of a pain assessment, they do not specifically address the key component of assessing the effectiveness of the interventions applied postoperatively.

4. A nurse is caring for a client with pneumonia who has a new prescription for antibiotics. Which of the following actions should the nurse take first?

• A. Administer the antibiotic immediately
• B. Obtain a sputum culture
• C. Notify the provider of the prescription
• D. Check the client's allergy history

Correct answer: B

Rationale: The correct first action for the nurse to take when caring for a client with pneumonia who has a new prescription for antibiotics is to obtain a sputum culture. This is important to identify the specific bacteria causing the pneumonia before administering antibiotics. Administering the antibiotic immediately (Choice A) may not be appropriate without knowing the specific pathogen. Notifying the provider of the prescription (Choice C) is important but not the first action to be taken. Checking the client's allergy history (Choice D) is relevant but not the priority in this situation.

5. How should the nurse manage the client's pain if a client with a history of substance abuse is requesting pain medication?

• A. Administer the medication as requested
• B. Assess the patient's pain level first
• C. Administer a placebo to the client
• D. Refuse to give any medication to the client

Correct answer: B

Rationale: When a client with a history of substance abuse requests pain medication, the nurse should first assess the patient's pain level. It is important to determine the nature and intensity of the pain before administering any medication to ensure appropriate pain management. Administering medication without assessing the pain level can lead to unnecessary drug administration or inadequate pain relief. Administering a placebo would be unethical and ineffective. Refusing to give any medication without proper assessment can compromise the client's comfort and recovery. Therefore, the correct approach is to assess the patient's pain level first before deciding on the most suitable pain management intervention.

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