Nursing Elites

1. A nurse is planning care for a client who is receiving hemodialysis via an AV fistula. Which of the following interventions should the nurse include in the plan of care?

• A. Avoid taking blood pressures on the arm with the AV fistula.
• B. Check the fistula site daily for pallor.
• C. Place a warm compress over the fistula site every 4 hours.
• D. Keep the client's arm elevated on two pillows.

Correct answer: A

Rationale: The correct intervention is to avoid taking blood pressures on the arm with the AV fistula. This is crucial to prevent complications such as damage to the fistula. Checking the fistula site for pallor is not as important as avoiding blood pressures on the affected arm. Placing warm compresses over the fistula site is not recommended as it can increase the risk of infection. Keeping the client's arm elevated on two pillows is not necessary for the care of an AV fistula.

2. A healthcare provider is assessing a client who has received a preoperative dose of morphine. Which of the following findings is the priority to report to the provider?

• A. Client reports nausea.
• B. Urinary output of 20 mL/hr.
• C. Oxygen saturation 90%.
• D. Respiratory rate 14/min.

Correct answer: C

Rationale: An oxygen saturation of 90% is below the expected reference range and could indicate respiratory depression, a serious side effect of morphine. This finding requires immediate attention as it may lead to hypoxia. Nausea (choice A) is a common side effect of morphine but does not pose an immediate threat. A urinary output of 20 mL/hr (choice B) may indicate decreased renal perfusion but is not as critical as respiratory compromise. A respiratory rate of 14/min (choice D) is within the normal range and does not suggest immediate danger.

3. A client who had a vaginal delivery 4 hours ago has a fourth-degree perineal laceration. Which of the following interventions should the nurse recommend?

• A. Encourage ambulation
• B. Apply ice packs
• C. Restrict the client's fluid intake
• D. Administer stool softeners

Correct answer: B

Rationale: Correct Answer: Applying ice packs is the most appropriate intervention for a client with a fourth-degree perineal laceration. Ice packs help reduce swelling and promote comfort, aiding in the healing process. Choice A, encouraging ambulation, may not be suitable immediately after a fourth-degree laceration due to the need for rest and proper wound care. Choice C, restricting fluid intake, is not indicated and can lead to dehydration, which is not beneficial for wound healing. Choice D, administering stool softeners, may be necessary to prevent constipation and straining, but it is not the priority intervention at this time.

4. A client with a tracheostomy shows signs of respiratory distress. What action should the nurse take immediately?

• A. Increase the suction setting on the ventilator
• B. Administer a bronchodilator
• C. Suction the tracheostomy
• D. Encourage deep breathing exercises

Correct answer: C

Rationale: The correct immediate action for a client with a tracheostomy showing signs of respiratory distress is to suction the tracheostomy. Respiratory distress in this case is often caused by a blockage, which can be quickly relieved by suctioning to clear the airway. Increasing the suction setting on the ventilator (Choice A) may not address the immediate blockage in the tracheostomy. Administering a bronchodilator (Choice B) may help with bronchoconstriction but does not address the potential blockage in the tracheostomy. Encouraging deep breathing exercises (Choice D) may not be effective in relieving the immediate respiratory distress caused by a blocked tracheostomy.

5. What is an essential nursing intervention for a client experiencing delirium?

• A. Control behavioral symptoms with low-dose psychotropics
• B. Identify the underlying causative condition
• C. Increase environmental stimulation
• D. Administer antipsychotic medication

Correct answer: B

Rationale: The correct answer is B - 'Identify the underlying causative condition.' When a client is experiencing delirium, it is crucial to determine the root cause of this acute change in mental status. This can involve a thorough assessment to identify any medical conditions, medications, infections, or environmental factors that may be contributing to the delirium. By pinpointing the underlying cause, appropriate interventions can be implemented to address the specific issue. Choices A, C, and D are incorrect because controlling behavioral symptoms with low-dose psychotropics, increasing environmental stimulation, and administering antipsychotic medication do not target the primary need of identifying and addressing the causative condition of delirium.

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