Nursing Elites

1. What is the best intervention for a patient presenting with respiratory distress?

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

Correct answer: A

Rationale: Administering oxygen is the most critical intervention for a patient in respiratory distress as it helps improve oxygenation levels. Oxygen therapy aims to increase oxygen saturation in the blood, providing relief and support during episodes of respiratory distress. Administering bronchodilators may be beneficial in some cases, but oxygen therapy takes precedence in addressing the underlying issue of inadequate oxygenation. Repositioning the patient may help optimize ventilation but does not directly address the primary need for increased oxygen. Providing humidified air can offer comfort but does not address the urgent need for improved oxygen levels in a patient experiencing respiratory distress.

2. What is the initial nursing action for a patient presenting with chest pain?

• A. Administer aspirin
• B. Reposition the patient
• C. Provide pain relief
• D. Prepare for surgery

Correct answer: A

Rationale: The correct initial nursing action for a patient presenting with chest pain is to administer aspirin. Aspirin helps reduce the risk of further clot formation in patients experiencing chest pain, as it has antiplatelet effects. Repositioning the patient, providing pain relief, or preparing for surgery are not the first-line interventions for chest pain. Repositioning the patient may be necessary to ensure comfort and safety, pain relief can be provided after further assessment and diagnostic tests, and preparing for surgery would only be considered after a thorough evaluation and confirmation of the need for surgical intervention.

3. A client, 12 hours postpartum, reports not having a bowel movement for 4 days. Which medication should the nurse administer?

• A. Bisacodyl 10 mg rectal suppository.
• B. Magnesium hydroxide 30 ml PO.
• C. Famotidine 20 mg PO.
• D. Loperamide 4 mg PO.

Correct answer: A

Rationale: In this scenario, the nurse should administer Bisacodyl 10 mg rectal suppository. The client's report of not having a bowel movement for 4 days indicates constipation, and Bisacodyl is a stimulant laxative that helps initiate bowel movements. Magnesium hydroxide is an antacid and osmotic laxative used for indigestion, not for constipation. Famotidine is an H2 receptor antagonist used to reduce stomach acid production and treat heartburn, not constipation. Loperamide is an antidiarrheal agent and would be contraindicated in a client experiencing constipation.

4. A nurse is caring for a client with schizophrenia. Which of the following assessment findings should the nurse expect?

• A. Decreased level of consciousness
• B. Inability to identify common objects
• C. Poor problem-solving ability
• D. Preoccupation with somatic disturbances

Correct answer: B

Rationale: In schizophrenia, clients often display an inability to identify common objects due to cognitive impairment. This is known as associative agnosia, where individuals struggle to recognize familiar objects, faces, or sounds. Choices A, C, and D are not typically associated with schizophrenia. Decreased level of consciousness is more indicative of conditions like head trauma or drug overdose. Poor problem-solving ability may be seen in various mental health disorders but is not specific to schizophrenia. Preoccupation with somatic disturbances is more commonly seen in somatic symptom disorders or somatic delusions, not a typical finding in schizophrenia.

5. A client with heart failure is receiving digoxin. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 78/min.
• B. Vision changes.
• C. Respiratory rate of 16/min.
• D. Blood pressure of 120/80 mm Hg.

Correct answer: B

Rationale: The correct answer is B: Vision changes. Vision changes are a classic sign of digoxin toxicity and should be reported immediately to the provider for further evaluation and management. A heart rate of 78/min, a respiratory rate of 16/min, and a blood pressure of 120/80 mm Hg are within normal ranges and are not typically associated with digoxin toxicity. Therefore, they would not be the priority findings to report in this situation.

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