Nursing Elites

1. A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?

• A. A client who has sinus arrhythmia and is receiving cardiac monitoring.
• B. A client who has diabetes mellitus and a hemoglobin A1C of 6.8%.
• C. A client who has epidural analgesia and weakness in the lower extremities.
• D. A client who has a hip fracture and a new onset of tachypnea.

Correct answer: D

Rationale: The correct answer is D. New onset of tachypnea indicates a potential respiratory complication that requires immediate attention. Assessing the client with a hip fracture and tachypnea first is crucial to address the respiratory issue and prevent further deterioration. Choices A, B, and C do not present immediate life-threatening complications that require urgent assessment compared to a new onset of tachypnea.

2. A nurse is caring for a client who is experiencing a situational crisis following the loss of a job. The client states, 'I don't think I can go through this again.' Which of the following actions is the nurse's priority?

• A. Refer the client to a mental health counselor
• B. Encourage the client to express their feelings
• C. Determine if the client is experiencing psychotic thinking
• D. Ask the client about their social support system

Correct answer: C

Rationale: In this situation, the nurse's priority is to determine if the client is experiencing psychotic thinking as it addresses the immediate safety concern. Psychotic thinking may pose a risk to the client's safety or the safety of others. Referring the client to a mental health counselor (choice A) may be appropriate but not the priority when safety is a concern. Encouraging the client to express their feelings (choice B) and asking about their social support system (choice D) are essential aspects of care but are secondary to addressing immediate safety issues.

3. How should a healthcare provider respond to a patient with a suspected pulmonary embolism?

• A. Administer oxygen and call for emergency assistance
• B. Position the patient in a prone position and give fluids
• C. Administer anticoagulants and elevate the patient's legs
• D. Administer thrombolytics and perform chest physiotherapy

Correct answer: A

Rationale: Administering oxygen and calling for emergency assistance are the immediate priorities when managing a suspected pulmonary embolism. Oxygen helps support the patient's respiratory function, while emergency assistance is crucial for further evaluation and treatment. Positioning the patient in a prone position or giving fluids can worsen the condition by impeding blood flow. Administering anticoagulants may be part of the treatment plan but is not the initial response. Thrombolytics and chest physiotherapy are not first-line treatments for suspected pulmonary embolism and can even be harmful without prior evaluation.

4. A nurse is reviewing the plan of care for a client who is receiving chemotherapy for cancer. Which of the following interventions should the nurse include to prevent infection?

• A. Encourage the client to eat high-protein foods
• B. Encourage the client to drink 2 liters of fluid daily
• C. Instruct the client to use a soft toothbrush
• D. Instruct the client to use a mouthwash containing alcohol

Correct answer: C

Rationale: The correct answer is to instruct the client to use a soft toothbrush. Using a soft toothbrush helps prevent bleeding in clients receiving chemotherapy, who are at risk for mucositis. Encouraging the client to eat high-protein foods (Choice A) is important for overall health but not directly related to preventing infection. Encouraging the client to drink 2 liters of fluid daily (Choice B) is essential for hydration but does not specifically prevent infection. Instructing the client to use a mouthwash containing alcohol (Choice D) is contraindicated as alcohol-containing mouthwashes can cause irritation and dryness in the oral mucosa, increasing the risk of infection.

5. How can pain in a post-operative patient be managed effectively?

• A. Administer analgesics as prescribed
• B. Encourage deep breathing exercises
• C. Provide distractions
• D. All of the above

Correct answer: D

Rationale: Managing pain in a post-operative patient requires a multimodal approach, which includes both pharmacological and non-pharmacological strategies. Administering analgesics as prescribed helps in controlling pain pharmacologically. Encouraging deep breathing exercises can aid in pain management by promoting relaxation and reducing anxiety. Providing distractions, such as music or activities, can help divert the patient's attention from pain. Therefore, all the given options are essential components of an effective pain management plan for post-operative patients.

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