Nursing Elites

1. After applying oxygen using bi-nasal prongs to a client who is having chest pain, the nurse should implement which intervention?

• A. Have the client take slow deep breaths in through their mouth and out through their nose.
• B. Post signs indicating that oxygen is in use on the client's door and in their room
• C. Apply Vaseline petroleum to both nares and 2 by 2 gauze around the oxygen tubing at the client's ears
• D. Encourage the client to hyperextend the neck, take a few deep breaths and cough.

Correct answer: A

Rationale: After applying oxygen using bi-nasal prongs to a client with chest pain, it is essential for the nurse to post signs indicating that oxygen is in use on the client's door and in their room. This safety precaution alerts healthcare providers and visitors that the client is receiving oxygen therapy, reducing the risk of accidents or misunderstandings. Choice A is incorrect because instructing the client to take slow deep breaths is not the appropriate intervention after applying oxygen. Choice C suggests applying Vaseline and gauze, which is unnecessary and not a standard practice. Choice D advising the client to hyperextend the neck, take deep breaths, and cough is not indicated after applying oxygen therapy and could potentially be harmful.

2. The client is taking Antabuse and should avoid eating foods that may trigger a disulfiram reaction. The nurse should instruct the client to avoid:

• A. Peanuts, dates, raisins
• B. Figs, chocolate, eggplant
• C. Pickles, salad with vinaigrette dressing, beef
• D. Milk, cottage cheese, ice cream

Correct answer: C

Rationale: The client taking Antabuse should avoid foods that contain alcohol or vinegar as they can trigger a disulfiram reaction. Pickles and vinaigrette dressing often contain vinegar, which the client should avoid. Beef is safe to consume. Choices A, B, and D do not contain alcohol or vinegar, so they are allowed for the client taking Antabuse.

3. A patient has experienced a severe third-degree burn to the trunk in the last 36 hours. Which phase of burn management is the patient in?

• A. Shock phase
• B. Emergent phase
• C. Healing phase
• D. Wound proliferation phase

Correct answer: A

Rationale: The correct answer is A: Shock phase. The shock phase occurs within the first 24-48 hours of burn management. During this phase, the focus is on stabilization, fluid resuscitation, and monitoring for potential complications. Choice B, the Emergent phase, is incorrect as it refers to the initial phase of burn care immediately after the injury. Choice C, the Healing phase, occurs later in the treatment process when the wound starts to repair itself. Choice D, the Wound proliferation phase, is not a recognized phase in burn management.

4. What task should the RN perform first?

• A. Changing a burn dressing that is scheduled every four hours.
• B. Doing pinsite care on a client in skeletal traction ordered TID.
• C. Teaching a newly diagnosed diabetic about diet and exercise.
• D. Assessing a newly admitted client.

Correct answer: D

Rationale: The correct answer is to assess a newly admitted client first. When a client is newly admitted, it is crucial to perform an assessment promptly. The initial assessment and establishment of a care plan should be completed within a specific timeframe to ensure the client's needs are met effectively. Choices A, B, and C involve important tasks but should be prioritized after the initial assessment of the newly admitted client to ensure timely and appropriate care delivery. Changing a burn dressing (Choice A) and doing pinsite care on a client in skeletal traction (Choice B) are time-sensitive tasks but can be safely delayed briefly to conduct the initial assessment. Teaching a newly diagnosed diabetic about diet and exercise (Choice C) is important for the client's long-term care but can be scheduled after the immediate needs assessment of the newly admitted client.

5. High uric acid levels can develop in clients who are receiving chemotherapy. This can be caused by

• A. the kidneys' inability to excrete the drug metabolites.
• B. rapid cell catabolism.
• C. toxic effects of the prophylactic antibiotics given concurrently.
• D. the altered blood pH from the acidic nature of the drugs.

Correct answer: B

Rationale: The correct answer is 'rapid cell catabolism.' Chemotherapy leads to the destruction of cells, resulting in increased uric acid levels due to cell breakdown. Choice A is incorrect because the issue is not with the kidneys' ability to excrete the drug metabolites but rather with the cell breakdown. Choice C is incorrect as the question focuses on chemotherapy and its effects, not prophylactic antibiotics. Choice D is incorrect as the question pertains to the development of high uric acid levels, not altered blood pH from acidic drugs.

Similar Questions