Nursing Elites

1. When administering ceftriaxone sodium (Rocephin) intravenously to a client, which assessment finding requires the most immediate intervention by the nurse?

• A. Stridor
• B. Nausea
• C. Headache
• D. Pruritus

Correct answer: A

Rationale: The correct answer is A: Stridor. Stridor is a high-pitched, noisy breathing sound that indicates a potential airway obstruction, which can be caused by an allergic reaction. This finding requires immediate intervention by the nurse to ensure the client's airway is patent and to prevent respiratory distress. Nausea, headache, and pruritus are potential side effects of ceftriaxone sodium but do not pose immediate life-threatening risks compared to airway obstruction indicated by stridor.

2. Which needle should the nurse use to administer intravenous fluids (IV) via a client's implanted port?

• A. The one with the clamp and no needle
• B. A butterfly needle
• C. A non-coring (Huber) needle
• D. A standard hypodermic needle

Correct answer: C

Rationale: The correct needle to use for administering intravenous fluids via an implanted port is a non-coring (Huber) needle. This type of needle is specifically designed to access implanted ports without coring the septum, which helps prevent damage. Choice A, the one with the clamp and no needle, is incorrect as it does not describe a needle suitable for accessing an implanted port. Choice B, a butterfly needle, is not typically used for accessing implanted ports. Choice D, a standard hypodermic needle, is not ideal for accessing ports as it can damage the septum.

3. A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Which assessment finding is most concerning to the nurse?

• A. Oxygen saturation of 90%
• B. Respiratory rate of 24 breaths per minute
• C. Use of accessory muscles
• D. Inspiratory crackles

Correct answer: C

Rationale: The correct answer is C: 'Use of accessory muscles.' In a client with a history of COPD, the use of accessory muscles indicates increased work of breathing and may signal respiratory failure, necessitating immediate intervention. This finding is concerning as it suggests the client is struggling to breathe adequately. Oxygen saturation of 90% (choice A) is low but may be expected in COPD patients; it requires monitoring and intervention but is not as immediately concerning as the use of accessory muscles. A respiratory rate of 24 breaths per minute (choice B) is within a normal range and, although slightly elevated, may be a typical response to pneumonia. Inspiratory crackles (choice D) can be a common finding in pneumonia and are not as indicative of impending respiratory failure as the use of accessory muscles.

4. The healthcare provider explains through an interpreter the risks and benefits of a scheduled surgical procedure to a non-English speaking female client. The client gives verbal consent, and the healthcare provider leaves, instructing the nurse to witness the signature on the consent form. The client and the interpreter then speak together in the foreign language for an additional 2 minutes until the interpreter concludes, 'She says it is OK.' What action should the nurse take next?

• A. Ask for a full explanation from the interpreter of the witnessed discussion.
• B. Have the client sign the consent form.
• C. Document the conversation and witness the consent.
• D. Ask the client directly if she has any questions.

Correct answer: A

Rationale: The correct action for the nurse to take next is to ask for a full explanation from the interpreter of the witnessed discussion. Verbal consent is not sufficient; it is crucial to ensure that the client fully comprehends the risks and benefits of the surgical procedure. By asking the interpreter to provide a detailed explanation of the discussion, the nurse can confirm that the client has given informed consent. Having the client sign the consent form (Choice B) without ensuring complete understanding may lead to potential misunderstandings. Documenting the conversation and witnessing the consent (Choice C) is not enough to guarantee the client's comprehension. Asking the client directly if she has any questions (Choice D) may not be effective if language barriers persist.

5. One day after abdominal surgery, an obese client complains of pain and heaviness in the right calf. What action should the nurse implement?

• A. Observe for unilateral swelling
• B. Administer pain medication
• C. Elevate the leg and apply a warm compress
• D. Notify the healthcare provider

Correct answer: A

Rationale: The correct action for the nurse to implement is to observe for unilateral swelling. Unilateral swelling could indicate a deep vein thrombosis (DVT), which is a serious complication that requires immediate assessment. Administering pain medication or applying warm compress may not address the underlying cause of the symptoms. Notifying the healthcare provider should be done after assessing and identifying the issue of unilateral swelling.

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