Nursing Elites

1. A post-operative client develops a sudden onset of chest pain and dyspnea. The nurse suspects a pulmonary embolism (PE). What is the priority nursing action?

• A. Administer oxygen via face mask.
• B. Elevate the client's legs.
• C. Prepare the client for immediate surgery.
• D. Notify the healthcare provider immediately.

Correct answer: A

Rationale: Administering oxygen via face mask is the priority nursing action in a post-operative client suspected of a pulmonary embolism. This intervention helps ensure adequate oxygenation while further assessments and interventions are initiated. Elevating the client's legs is not indicated for a suspected pulmonary embolism; it is more appropriate for conditions like shock. Immediate surgery is not the priority in this situation as the client is experiencing acute symptoms requiring prompt intervention. While notifying the healthcare provider is important, the immediate focus should be on providing oxygen to the client to support respiratory function.

2. What is the primary action a healthcare professional should take when a patient with a suspected myocardial infarction (MI) arrives in the emergency department?

• A. Apply a cold compress to the chest
• B. Administer oxygen and obtain an electrocardiogram (ECG)
• C. Encourage the patient to walk to reduce anxiety
• D. Provide a high-carbohydrate meal

Correct answer: B

Rationale: Administering oxygen and obtaining an ECG are crucial initial steps when managing a suspected myocardial infarction (MI). Oxygen helps improve oxygenation to the heart muscle, while an ECG is essential to diagnose an MI promptly. Applying a cold compress, encouraging the patient to walk, or providing a high-carbohydrate meal are not appropriate actions in the initial management of a suspected MI. Applying a cold compress can delay necessary interventions, encouraging the patient to walk may worsen the condition, and providing a high-carbohydrate meal is irrelevant to the immediate needs of a patient with a suspected MI.

3. A male client who has been diagnosed with schizophrenia is withdrawn, isolates himself in the day room, and answers questions with one or two-word responses. This morning, the practical nurse observes that he is diaphoretic and is pacing in the hall. Which intervention is most important for the PN to implement?

• A. Persuade the client to lie down
• B. Provide a drink high in electrolytes
• C. Observe the client during the shift
• D. Measure appropriate vital signs

Correct answer: D

Rationale: Measuring vital signs is crucial in this situation as it helps to determine if the client is experiencing a physical health issue or if the symptoms are related to a mental health crisis, such as anxiety or agitation. The presence of diaphoresis and pacing may indicate physiological changes requiring immediate attention. Providing a drink high in electrolytes or persuading the client to lie down may not address the underlying cause of the symptoms. Simply observing the client during the shift without taking necessary actions to assess his physiological status may delay appropriate intervention.

4. During the immediate postoperative period following a total hip replacement, which intervention is most important for the nurse to implement?

• A. Encourage the client to use a walker or cane when ambulating
• B. Keep the client's hip aligned with knees abducted
• C. Teach the client to sit on the side of the bed before standing
• D. Monitor urinary flow via an indwelling catheter

Correct answer: B

Rationale: Keeping the client's hip aligned with the knees abducted is crucial to prevent dislocation of the prosthesis, which is a priority immediately after total hip replacement surgery. This position helps maintain the stability of the new hip joint. Encouraging the client to use a walker or cane (Choice A) is important but not as critical as ensuring proper hip alignment. Teaching the client to sit on the side of the bed before standing (Choice C) is a good practice but not as essential as maintaining hip alignment. Monitoring urinary flow via an indwelling catheter (Choice D) is not directly related to preventing complications immediately after a total hip replacement.

5. A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. Which immediate intervention should the PN implement?

• A. Stimulate the infant to cry
• B. Give oxygen by positive pressure
• C. Suction the oral and nasal passages
• D. Turn the infant onto the right side

Correct answer: C

Rationale: Suctioning the oral and nasal passages is the correct immediate intervention in this scenario. Regurgitation leading to cyanosis indicates a potential airway obstruction, which requires prompt action to clear. Stimulating the infant to cry (Choice A) may not address the underlying issue of airway obstruction. Giving oxygen by positive pressure (Choice B) can be beneficial, but clearing the airway obstruction takes precedence. Turning the infant onto the right side (Choice D) does not directly address the need to clear the airway.

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