Nursing Elites

1. Several clients on a telemetry unit are scheduled for discharge in the morning, but a telemetry-monitored bed is needed immediately. The charge nurse should make arrangements to transfer which client to another medical unit?

• A. Learning to self-administer insulin injections after being diagnosed with diabetes mellitus
• B. Ambulatory following coronary artery bypass graft surgery performed six days ago
• C. Wearing a sling immobilizer following permanent pacemaker insertion earlier that day
• D. Experiencing syncopal episodes resulting from the dehydration caused by severe diarrhea

Correct answer: A

Rationale: The correct answer is A because transferring a stable client who is learning self-care, such as self-administering insulin injections after being diagnosed with diabetes mellitus, provides the needed telemetry-monitored bed without compromising the client's care. Choice B should not be transferred as the client is ambulatory following surgery and does not require telemetry monitoring. Choice C should not be transferred as the client is wearing a sling immobilizer following pacemaker insertion, which requires close monitoring. Choice D should not be transferred as the client is experiencing syncopal episodes due to severe dehydration, necessitating telemetry monitoring for immediate intervention.

2. A client with a history of heart failure is admitted to the hospital with worsening dyspnea. The nurse notes that the client has a productive cough with pink, frothy sputum. What action should the nurse take first?

• A. Administer oxygen
• B. Perform chest physiotherapy
• C. Elevate the head of the bed
• D. Obtain a sputum specimen

Correct answer: A

Rationale: In a client with heart failure presenting with worsening dyspnea and pink, frothy sputum (indicating pulmonary edema), the priority action for the nurse is to administer oxygen. Oxygen therapy helps improve oxygenation and alleviate dyspnea by increasing the oxygen supply to the lungs. Performing chest physiotherapy, elevating the head of the bed, or obtaining a sputum specimen are not the initial actions indicated in this situation and may delay addressing the client's immediate need for improved oxygenation.

3. The nurse is caring for a laboring 22-year-old primigravida following administration of regional anesthesia. In planning care for this client, what nursing intervention has the highest priority?

• A. Raising the side rails and placing the call bell within reach
• B. Teaching the client how to push effectively to decrease the length of the second stage of labor
• C. Timing and recording uterine contractions
• D. Positioning the client for proper distribution of anesthesia

Correct answer: A

Rationale: The highest priority nursing intervention for a laboring client following administration of regional anesthesia is to ensure safety by raising the side rails and placing the call bell within reach. This is crucial to prevent falls and to ensure that the client can call for assistance if needed. Teaching the client how to push effectively (Choice B) is important but not the highest priority at this moment. Timing and recording uterine contractions (Choice C) are essential but not as immediate as ensuring safety post-anesthesia. Positioning the client for proper distribution of anesthesia (Choice D) is important but ensuring immediate safety takes precedence in this situation.

4. A client with a history of seizures is being discharged with a prescription for phenytoin (Dilantin). Which instruction should the nurse provide this client?

• A. Take the medication with meals
• B. Avoid alcohol while taking this medication
• C. Limit sodium intake
• D. Take the medication at bedtime

Correct answer: B

Rationale: The correct instruction is to advise the client to avoid alcohol while taking phenytoin. Alcohol can interact with phenytoin, making it less effective and leading to increased side effects. Taking the medication with meals (Choice A) may help reduce gastrointestinal upset but is not the most crucial instruction for this medication. Limiting sodium intake (Choice C) is not directly related to phenytoin therapy. Taking the medication at bedtime (Choice D) is not a standard instruction for phenytoin administration.

5. The nurse is planning care for a 2-year-old child who is scheduled for an infusion of immune globulin for treatment of idiopathic thrombocytopenic purpura (ITP). Which nursing diagnosis has the highest priority for this child?

• A. Risk for infection
• B. Risk for injury
• C. Altered oral mucous membranes
• D. Risk for fluid volume deficit

Correct answer: A

Rationale: The correct answer is 'Risk for infection.' When caring for a child with ITP scheduled for immune globulin infusion, the highest priority is to prevent infection. This is crucial due to the risk of bleeding associated with ITP and the immunosuppression that can be caused by the condition and its treatment. The other options, such as 'Risk for injury,' 'Altered oral mucous membranes,' and 'Risk for fluid volume deficit,' are not as high a priority as preventing infection in this particular situation.

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