Nursing Elites

1. What is the best intervention for a patient experiencing hypoxia?

• A. Administer oxygen
• B. Reposition the patient
• C. Provide humidified air
• D. Provide chest physiotherapy

Correct answer: A

Rationale: The best intervention for a patient experiencing hypoxia is to administer oxygen. Oxygen therapy helps improve oxygenation levels in the blood, addressing the underlying cause of hypoxia. Repositioning the patient, providing humidified air, and chest physiotherapy may be beneficial in certain situations but are not the primary interventions for hypoxia. Administering oxygen is crucial to quickly alleviate hypoxia and support the patient's respiratory function.

2. A client is 2 hours postoperative following a cholecystectomy. Which of the following interventions should the nurse implement?

• A. Place the client in a supine position
• B. Administer morphine for pain relief
• C. Apply a warm compress to the incision site
• D. Place a pillow under the client's knees

Correct answer: B

Rationale: Administering morphine for pain relief is crucial for postoperative clients following a cholecystectomy to manage pain effectively. Placing the client in a supine position may not be ideal as it can cause discomfort and hinder breathing. Applying a warm compress to the incision site can increase the risk of infection. Placing a pillow under the client's knees is not a priority intervention compared to pain management.

3. A nurse is planning care for a client who has pneumonia. Which of the following actions should the nurse take to promote airway clearance?

• A. Perform chest physiotherapy every 4 hours.
• B. Suction the client every 2 hours.
• C. Encourage the client to increase fluid intake.
• D. Administer oxygen via nasal cannula.

Correct answer: C

Rationale: Encouraging the client to increase fluid intake is essential in promoting airway clearance for a client with pneumonia. Increased fluid intake helps thin secretions, making it easier for the client to clear their airways. Chest physiotherapy (Choice A) is more focused on mobilizing secretions and may not be suitable for all clients with pneumonia. Suctioning (Choice B) is indicated for clients who have excessive secretions that they cannot manage effectively themselves. Administering oxygen via nasal cannula (Choice D) is important for clients with pneumonia to maintain adequate oxygenation, but it does not directly promote airway clearance.

4. A nurse is assessing a newborn's heart rate. Which of the following actions should the nurse take?

• A. Auscultate the apical pulse and count for 1 minute
• B. Place a sensor on the index finger
• C. Heat the skin prior to placing the probe
• D. Recheck after 10 minutes

Correct answer: A

Rationale: Corrected Rationale: Auscultating the apical pulse and counting for one minute is the appropriate method to accurately measure a newborn's heart rate. The apical pulse is located at the point of maximum impulse (PMI), which is usually at the fourth or fifth intercostal space along the mid-clavicular line. This method allows for a precise assessment of the newborn's heart rate. Choice B, placing a sensor on the index finger, is incorrect because this method is more suitable for measuring oxygen saturation rather than heart rate. Choice C, heating the skin prior to placing the probe, is unnecessary for assessing heart rate and may lead to potential burns in newborns. Choice D, rechecking after 10 minutes, is not appropriate as immediate assessment and intervention may be required if an abnormal heart rate is detected in a newborn.

5. A healthcare professional is preparing to administer an intermittent enteral feeding to a client who has an NG tube. Which of the following actions should the healthcare professional take first?

• A. Check the residual volume.
• B. Flush the tube with 0.9% sodium chloride.
• C. Elevate the head of the bed to 45 degrees.
• D. Warm the formula to body temperature.

Correct answer: C

Rationale: Elevating the head of the bed to 45 degrees is the priority action before administering an enteral feeding through an NG tube. This position helps prevent aspiration by promoting proper flow and digestion of the feeding. Checking the residual volume, flushing the tube, and warming the formula are important steps but come after ensuring the client is in the correct position to minimize the risk of complications.

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