Nursing Elites

1. The nurse is caring for a client who is 2 days post-op following an abdominal surgery. The client reports feeling something 'give way' in the incision site and there is a small amount of bowel protruding from the wound. What action should the nurse take first?

• A. Apply a sterile saline dressing to the wound
• B. Notify the healthcare provider
• C. Administer pain medication
• D. Cover the wound with an abdominal binder

Correct answer: A

Rationale: In this situation, the priority action for the nurse is to apply a sterile saline dressing to the wound. This helps prevent infection and keeps the wound moist, which is crucial in promoting healing and preventing further complications. Option B, notifying the healthcare provider, is important but should come after addressing the wound. Administering pain medication (Option C) may be necessary but is not the first action to take in this emergency situation. Covering the wound with an abdominal binder (Option D) is not appropriate and may cause further harm by applying pressure to the protruding bowel.

2. The nurse is performing a physical assessment of a male client who has chronic renal failure. Which assessment finding is most important for the nurse to report to the healthcare provider?

• A. Client reports difficulty breathing
• B. Client reports shortness of breath when lying flat
• C. Client reports swelling in the feet and ankles
• D. Client reports a metallic taste in the mouth

Correct answer: A

Rationale: In a client with chronic renal failure, difficulty breathing is the most critical finding to report. This symptom may indicate fluid overload or pulmonary edema, which can be life-threatening. Shortness of breath when lying flat (orthopnea) is also concerning but less urgent than difficulty breathing. Swelling in the feet and ankles (edema) is a common finding in renal failure but may not be as immediately critical as difficulty breathing. A metallic taste in the mouth is associated with uremia, a common complication of chronic renal failure, but it is not as urgent as respiratory distress.

3. 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.

4. A client is taught how to collect a 24-hour urine specimen. Which statement indicates understanding of the procedure?

• A. I should keep the urine specimen refrigerated.
• B. I need to start the collection in the morning after my first void.
• C. I will collect the urine for 24 hours and keep it on ice.
• D. I will start collecting the urine after discarding my first morning specimen.

Correct answer: D

Rationale: The correct way to collect a 24-hour urine specimen is to discard the first morning void and then start the collection. Choice A is incorrect because refrigeration is not typically necessary for a 24-hour urine specimen. Choice B is incorrect as the client needs to discard the first void. Choice C is incorrect; while collecting urine for 24 hours is correct, keeping it on ice is not standard procedure.

5. The nurse-manager of a perinatal unit is notified that one client from the medical-surgical unit needs to be transferred to make room for new admissions. Which client should the nurse recommend for transfer to the antepartal unit?

• A. A 45-year-old with chronic hepatitis B.
• B. A 35-year-old with lupus erythematosus
• C. A 19-year-old diagnosed with rubella
• D. A 25-year-old with herpes lesions of the vulva

Correct answer: B

Rationale: The correct answer is B because a client with lupus erythematosus can be safely transferred to the antepartal unit as this condition does not pose a significant risk to other patients or staff. Choices A, C, and D should not be recommended for transfer to the antepartal unit due to the potential risks they may pose to pregnant women and their unborn babies. Chronic hepatitis B, rubella, and herpes lesions of the vulva can be contagious and harmful in the perinatal setting.

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