Nursing Elites

1. The nurse is caring for a client who is receiving continuous ambulatory peritoneal dialysis (CAPD) and notes that the output flow is 100ml less than the input flow. Which actions should the nurse implement first?

• A. Continue to monitor intake and output with the next exchange
• B. Check the client's blood pressure and serum bicarbonate levels
• C. Irrigate the dialysis catheter
• D. Change the client's position

Correct answer: D

Rationale: In this situation, the priority action for the nurse is to change the client's position. Altering the client's position can help facilitate better fluid drainage in peritoneal dialysis, potentially resolving the issue without the need for more invasive interventions. Continuing to monitor intake and output (Choice A) is important but addressing the immediate drainage issue takes precedence. Checking blood pressure and serum bicarbonate levels (Choice B) is not directly related to the observed output flow discrepancy. Irrigating the dialysis catheter (Choice C) should not be the initial action as it is more invasive and should be considered only if repositioning does not resolve the issue.

2. The nurse is preparing to administer an oral antibiotic to a client with unilateral weakness, ptosis, mouth drooping, and aspiration pneumonia. What is the priority nursing assessment that should be done before administering this medication?

• A. Ask the client about soft food preferences
• B. Auscultate the client’s breath sounds
• C. Obtain and record the client’s vital signs
• D. Determine which side of the body is weak

Correct answer: B

Rationale: The correct answer is to auscultate the client’s breath sounds. Assessing breath sounds is crucial in this scenario as it helps ensure that the client can safely swallow the oral antibiotic without aspirating. Unilateral weakness, ptosis, mouth drooping, and aspiration pneumonia indicate potential swallowing difficulties, making it essential to assess breath sounds for any signs of respiratory issues. Asking about food preferences (choice A) may be relevant later but is not the priority before administering the medication. While obtaining vital signs (choice C) is important, assessing breath sounds takes precedence in this case. Determining which side of the body is weak (choice D) is not the priority assessment before administering the oral antibiotic.

3. The nurse is evaluating a client who has had a mastectomy and is experiencing pain and swelling in the arm on the affected side. What action should the nurse take?

• A. Assess for signs of lymphedema
• B. Encourage the client to perform arm exercises
• C. Provide pain relief through medication
• D. Recommend wearing a compression sleeve

Correct answer: A

Rationale: Assessing for signs of lymphedema is crucial in this situation as it is a common complication following mastectomy. Lymphedema presents as swelling and pain in the affected arm due to compromised lymphatic drainage. By assessing for lymphedema, the nurse can identify the condition early and implement appropriate interventions such as compression sleeves, manual lymphatic drainage, and exercises. Encouraging arm exercises (Choice B) may exacerbate the symptoms if lymphedema is present. While providing pain relief through medication (Choice C) is important, assessing for the underlying cause of pain and swelling takes precedence. Recommending a compression sleeve (Choice D) may be suitable but should come after a thorough assessment for lymphedema to ensure the most effective management plan.

4. A client with eczema is experiencing severe pruritus. Which PRN prescription should the nurse administer?

• A. Topical corticosteroid
• B. Topical scabicide
• C. Topical alcohol rub
• D. Transdermal analgesic

Correct answer: A

Rationale: The correct answer is A: Topical corticosteroid. Topical corticosteroids are commonly used to manage itching in eczema by reducing inflammation and suppressing the immune response. In this case, for severe pruritus in eczema, a topical corticosteroid would be appropriate. Choice B, Topical scabicide, is used to treat scabies, not eczema. Choice C, Topical alcohol rub, is not typically used to manage pruritus in eczema. Choice D, Transdermal analgesic, is more for pain relief and not specifically targeted at managing itching associated with eczema.

5. A client who will be going to surgery states no known allergies to any medications. What is the most important nursing action for the nurse to implement next?

• A. Assess client’s knowledge of an allergic response
• B. Record 'no known drug allergies' on the preoperative checklist
• C. Flag 'no known drug allergies' on the front of the chart
• D. Assess client’s allergies to non-drug substances

Correct answer: B

Rationale: The most important action to take in this situation is to record 'no known drug allergies' on the preoperative checklist. This ensures that all healthcare staff involved in the surgery are aware of the client's stated lack of drug allergies, helping to prevent any potential adverse reactions. Assessing the client's knowledge of an allergic response (Choice A) may be valuable but is not the most crucial action at this point. Flagging 'no known drug allergies' on the front of the chart (Choice C) is less practical and visible compared to documenting it on the preoperative checklist. Assessing the client’s allergies to non-drug substances (Choice D) is not the priority in this scenario where the focus is on medications due to the upcoming surgery.

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