Nursing Elites

1. While suctioning the endotracheal tube of a client on a ventilator, the nurse notices an increase in the client's heart rate from 86/min to 110/min, with irregularity. What should the nurse do next?

• A. Obtain a cardiology consult.
• B. Suction the client less frequently.
• C. Administer an antidysrhythmic medication.
• D. Perform pre-oxygenation prior to suctioning.

Correct answer: D

Rationale: When a client's heart rate increases and becomes irregular during suctioning of an endotracheal tube, it indicates potential hypoxemia. Performing pre-oxygenation before suctioning helps prevent hypoxemia and subsequent dysrhythmias. This intervention ensures that the client has adequate oxygen reserves before the procedure, reducing the risk of complications related to suctioning.

2. A client is 4 hours postoperative following abdominal surgery. The client's blood pressure has dropped from 120/80 mm Hg to 90/60 mm Hg. What action should the nurse take first?

• A. Administer an IV fluid bolus.
• B. Check the surgical site for bleeding.
• C. Place the client in a Trendelenburg position.
• D. Notify the healthcare provider.

Correct answer: B

Rationale: Checking the surgical site for bleeding is crucial in this situation as it helps determine if the drop in blood pressure is due to hemorrhage, a potential postoperative complication. Identifying and addressing bleeding promptly is essential to prevent further complications and stabilize the client's condition.

3. When caring for a client with acute pancreatitis, what intervention is most appropriate?

• A. Encourage a high-protein diet.
• B. Administer pain medication as needed.
• C. Provide small, frequent meals.
• D. Increase oral fluid intake.

Correct answer: B

Rationale: Administering pain medication as needed is the most appropriate intervention for a client with acute pancreatitis. Pain management is crucial as pancreatitis can cause severe and debilitating pain. Providing pain relief is essential to improve the client's comfort and well-being.

4. A client with Parkinson's disease is prescribed carbidopa-levodopa (Sinemet). What should the nurse include in the teaching about this medication?

• A. Take the medication without a high-protein meal.
• B. Expect the medication to take several weeks to reach full effectiveness.
• C. The medication may cause urine to turn light.
• D. You may experience a rapid heartbeat as a common side effect.

Correct answer: B

Rationale: Patients prescribed carbidopa-levodopa should be informed that it may take several weeks for the medication to reach its full therapeutic effectiveness in managing Parkinson's disease symptoms. This delayed onset of action is important for patients to be aware of to prevent premature discontinuation of the medication due to perceived lack of efficacy.

5. The client is prescribed a long-acting beta2 agonist and expresses concerns about the cost, stating they only use the inhaler during asthma attacks. How should the nurse respond?

• A. Explain the importance of using the inhaler daily to prevent asthma attacks.
• B. Suggest identifying community services to help with the cost and encourage daily use of the inhaler.
• C. Explore the client's fears regarding breathlessness.
• D. Emphasize the necessity of using this inhaler daily and discuss potential community services for financial assistance.

Correct answer: B

Rationale: The correct response should address the client's concern about the cost of using the inhaler daily. While emphasizing the importance of daily use is crucial, it is also essential to acknowledge and offer support for the financial burden. Identifying community resources can help the client access affordable medications. Exploring fears related to breathlessness does not directly address the client's financial concerns.

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