Nursing Elites

1. What is the first intervention when a patient has difficulty breathing post-surgery?

• A. Administer oxygen
• B. Reposition the patient
• C. Check oxygen saturation
• D. Elevate the head of the bed

Correct answer: A

Rationale: Administering oxygen is the initial intervention for a patient experiencing breathing difficulties post-surgery. Providing oxygen helps improve oxygenation and alleviate respiratory distress. Repositioning the patient, checking oxygen saturation, and elevating the head of the bed are important interventions but administering oxygen takes precedence in addressing hypoxia and respiratory compromise.

2. A nurse is caring for a client who has experienced intimate partner violence. What is the nurse's priority?

• A. Develop a safety plan with the client.
• B. Refer the client to a community support group.
• C. Determine if the client has any injuries.
• D. Contact the client's family about the incident.

Correct answer: A

Rationale: The correct answer is A: 'Develop a safety plan with the client.' When caring for a client who has experienced intimate partner violence, the nurse's priority is to ensure the client's safety. Developing a safety plan is essential to address the immediate safety concerns and provide support to the client. Referring the client to a community support group, as in option B, may be beneficial but is not the immediate priority. While determining if the client has any injuries, as in option C, is important for assessing physical well-being, the priority is to address safety concerns first. Contacting the client's family about the incident, as in option D, is not appropriate without the client's consent and may further endanger the client.

3. A client with diabetes mellitus is receiving discharge instructions from a nurse. Which statement by the client indicates an understanding of the teaching?

• A. I will monitor my blood sugar level once a week.
• B. I will exercise every day even if my blood sugar is low.
• C. I will eat snacks rich in carbohydrates if my blood sugar drops.
• D. I will avoid sugary foods to prevent my blood sugar from rising.

Correct answer: C

Rationale: The correct answer is C. Eating snacks rich in carbohydrates is essential to manage hypoglycemia by raising blood sugar levels. Option A is incorrect as monitoring blood sugar once a week is not frequent enough for effective diabetes management. Option B is incorrect because exercising when blood sugar is low can worsen hypoglycemia. Option D is incorrect as it focuses on preventing high blood sugar levels, not managing low blood sugar.

4. What is the priority nursing intervention for a patient experiencing a myocardial infarction?

• A. Administer aspirin
• B. Administer nitroglycerin
• C. Administer morphine
• D. Prepare for surgery

Correct answer: A

Rationale: The correct answer is to administer aspirin. Administering aspirin is a priority nursing intervention for a patient experiencing a myocardial infarction because it helps reduce the risk of further clot formation. Aspirin is a common medication given during the early stages of a heart attack to prevent additional clotting. Administering nitroglycerin may also be indicated to help relieve chest pain by dilating blood vessels, but aspirin takes precedence due to its role in preventing clot progression. Administering morphine is not typically the first intervention in myocardial infarction as it can mask symptoms and delay other critical treatments. Surgery is not an immediate priority in the initial management of a myocardial infarction.

5. A nurse is assessing a client who is 48 hours postoperative following a hip replacement. Which of the following findings should the nurse report to the provider?

• A. Heart rate 90/min.
• B. WBC count 15,000/mm3.
• C. Urinary output 75 mL in the past 4 hours.
• D. Temperature 37.8°C (100°F).

Correct answer: B

Rationale: An elevated WBC count 48 hours postoperatively may indicate an infection and should be reported to the provider. Choice A, a heart rate of 90/min, is within normal limits and not a concerning finding postoperatively. Choice C, urinary output of 75 mL in the past 4 hours, may indicate decreased renal perfusion, but an elevated WBC count is a more urgent finding. Choice D, a temperature of 37.8°C (100°F), which is slightly elevated, could be indicative of the body's normal response to surgery and is not as alarming as an elevated WBC count.

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