Nursing Elites

1. A patient is experiencing shortness of breath. What is the nurse's immediate action?

• A. Assist the patient into a high Fowler's position.
• B. Administer oxygen at 2 liters per minute via nasal cannula.
• C. Encourage the patient to take deep breaths and cough.
• D. Assess the patient's lung sounds.

Correct answer: B

Rationale: Administering oxygen at 2 liters per minute via nasal cannula is the immediate action for a patient experiencing shortness of breath. This intervention helps to improve oxygenation and relieve respiratory distress promptly. Placing the patient in a high Fowler's position (choice A) may also be beneficial but providing oxygen takes precedence in this scenario to address the underlying hypoxemia. Encouraging deep breaths and coughing (choice C) may not be appropriate as the first action, especially without assessing the patient first. Assessing lung sounds (choice D) is essential but should follow the initial intervention of administering oxygen.

2. A healthcare professional is planning care for a client who is scheduled for a lumbar puncture. Which of the following actions should the healthcare professional include?

• A. Restrict the client's fluid intake for 4 hours following the procedure
• B. Apply cold compresses to the puncture site after the procedure
• C. Instruct the client to increase oral fluid intake after the procedure
• D. Keep the client in a prone position for 12 hours after the procedure

Correct answer: C

Rationale: The correct action to include in caring for a client scheduled for a lumbar puncture is to instruct the client to increase oral fluid intake after the procedure. Increasing oral fluid intake helps replace cerebrospinal fluid lost during the lumbar puncture and reduces the risk of headaches. Restricting fluid intake (Choice A) is not recommended as it can lead to dehydration. Applying cold compresses (Choice B) is not necessary after a lumbar puncture. Keeping the client in a prone position for 12 hours (Choice D) is not required after a lumbar puncture and can cause discomfort and complications.

3. What are the nursing priorities when caring for a patient with a newly placed peripherally inserted central catheter (PICC)?

• A. Performing sterile dressing changes
• B. Educating the patient on PICC line care
• C. Flushing the PICC line as prescribed
• D. Inspecting the insertion site for signs of infection

Correct answer: A

Rationale: The correct answer is A: Performing sterile dressing changes. When caring for a patient with a newly placed PICC line, one of the nursing priorities is to ensure proper care of the insertion site by performing sterile dressing changes. This helps prevent infections and maintain the integrity of the line. While educating the patient on PICC line care, flushing the PICC line as prescribed, and inspecting the insertion site for signs of infection are important aspects of care, the priority immediately after insertion is to maintain the sterility of the site through proper dressing changes.

4. A nurse is providing discharge instructions to a client following a gastrectomy. Which of the following strategies should the nurse include in the teaching?

• A. Drink fluids between meals
• B. Eat three large meals each day
• C. Lie down for 30 minutes after meals
• D. Avoid drinking liquids with meals

Correct answer: D

Rationale: The correct strategy to include in the teaching after a gastrectomy is to avoid drinking liquids with meals. This helps prevent dumping syndrome, a condition characterized by rapid emptying of undigested food and fluids from the stomach into the small intestine. Choices A, B, and C are incorrect. Drinking fluids between meals is appropriate to maintain hydration, eating three large meals can exacerbate dumping syndrome, and lying down after meals is not recommended as it can increase the risk of reflux.

5. A nurse manager is presenting to a group of unit nurses the categories regulated under the Controlled Substances Act. Which of the following medications should the nurse include under Schedule II?

• A. Buprenorphine hydrochloride
• B. Hydrocodone bitartrate
• C. Diazepam
• D. Morphine

Correct answer: B

Rationale: The correct answer is B: Hydrocodone bitartrate. According to the Controlled Substances Act, hydrocodone bitartrate is classified as a Schedule II controlled substance due to its high potential for abuse and addiction. Diazepam (Choice C) and morphine (Choice D) are classified as Schedule IV and Schedule II controlled substances, respectively. Buprenorphine hydrochloride (Choice A) is classified as a Schedule III controlled substance. Therefore, hydrocodone bitartrate should be included under Schedule II medications when discussing the categories regulated under the Controlled Substances Act.

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