Nursing Elites

1. The nurse is assessing a client with a small bowel obstruction who was hospitalized 24 hours ago. Which assessment finding should the nurse report immediately to the healthcare provider?

• A. Hypoactive bowel sounds in the lower quadrant.
• B. Rebound tenderness in the upper quadrants.
• C. Tympany with percussion of the abdomen.
• D. Light-colored gastric aspirate via the nasogastric tube.

Correct answer: B

Rationale: Rebound tenderness in the upper quadrants may indicate peritonitis, which requires prompt medical attention. Hypoactive bowel sounds are expected in small bowel obstruction and would not be a priority over signs of peritonitis. Tympany with percussion is a normal finding and not a cause for immediate concern. Light-colored gastric aspirate could indicate various issues but is not as urgent as peritonitis.

2. The charge nurse observes a new nurse preparing to insert an intravenous (IV) catheter. The new nurse has gathered supplies, including intravenous catheters, an intravenous insertion kit, and a 4x4 sterile gauze dressing to cover and secure the insertion site. What action should the charge nurse take?

• A. Instruct the nurse to use a transparent dressing over the site
• B. Allow the new nurse to proceed with the procedure
• C. Assist the new nurse with the insertion
• D. Replace the 4x4 gauze with a larger dressing

Correct answer: A

Rationale: The correct answer is to instruct the nurse to use a transparent dressing over the site. Transparent dressings allow for continuous observation of the IV site, reducing the risk of complications. Choice B is incorrect because the charge nurse should intervene to ensure the new nurse follows best practices. Choice C is incorrect as the charge nurse should not just assist but provide guidance on the correct procedure. Choice D is incorrect because the size of the dressing is not the issue; it's the type of dressing that allows for better observation.

3. The nurse is assessing a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which laboratory value should be closely monitored?

• A. Serum potassium level
• B. Hemoglobin level
• C. White blood cell count
• D. Serum sodium level of 135 mEq/L

Correct answer: A

Rationale: The correct answer is A: Serum potassium level. In clients receiving erythropoietin therapy for chronic kidney disease, monitoring serum potassium levels is crucial due to the risk of developing hyperkalemia. Erythropoietin therapy can stimulate red blood cell production, leading to an increase in potassium levels. Monitoring potassium levels helps prevent complications associated with hyperkalemia, such as cardiac arrhythmias. Choices B, C, and D are incorrect because while hemoglobin levels are relevant for assessing the effectiveness of erythropoietin therapy, monitoring potassium levels is more critical due to the potential adverse effects of elevated potassium levels in CKD patients on this therapy.

4. The nurse enters a client's room and observes the unlicensed assistive personnel (UAP) making an occupied bed. What action should the nurse take first?

• A. Place the side rails in an up position.
• B. Assist the UAP in turning the client.
• C. Provide instructions on proper bed-making techniques.
• D. Ask the client if they are comfortable.

Correct answer: A

Rationale: The correct answer is to place the side rails in an up position first. This action is essential to prevent the client from falling while the bed is being made. Assisting the UAP in turning the client (Choice B) is not the immediate priority. Providing instructions on bed-making techniques (Choice C) can wait until the safety of the client is ensured. Asking the client if they are comfortable (Choice D) is important but should come after ensuring the client's safety by raising the side rails.

5. A client with a history of chronic heart failure is admitted with shortness of breath and crackles in the lungs. Which intervention should the nurse implement first?

• A. Administer oxygen therapy as prescribed.
• B. Administer a loop diuretic as prescribed.
• C. Administer intravenous morphine as prescribed.
• D. Obtain an arterial blood gas (ABG) sample.

Correct answer: A

Rationale: Administering oxygen therapy is the priority intervention for a client with chronic heart failure presenting with shortness of breath and crackles in the lungs. Oxygen therapy helps improve oxygenation, which is crucial in managing respiratory distress. Loop diuretics (Choice B) may be indicated to manage fluid overload in heart failure but are not the immediate priority in this case. Administering morphine (Choice C) is not the first-line intervention for shortness of breath in heart failure and should be considered after addressing oxygenation and underlying causes. Obtaining an arterial blood gas sample (Choice D) can provide valuable information but is not the initial action needed to address the client's acute respiratory distress.

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