Nursing Elites

1. While eating at a restaurant, a gravid woman begins to choke and is unable to speak. What action should the nurse who witnesses the event take?

• A. Cardiopulmonary resuscitation with uterine tilt
• B. The Heimlich maneuver using chest thrusts
• C. The Heimlich maneuver using subdiaphragmatic thrusts
• D. Call 911 immediately then begin cardiopulmonary resuscitation

Correct answer: C

Rationale: The correct action for the nurse to take when a pregnant woman is choking and unable to speak is to perform the Heimlich maneuver using subdiaphragmatic thrusts. This technique is recommended for a pregnant woman to prevent harm to the fetus. Option A, cardiopulmonary resuscitation with uterine tilt, is not indicated for a choking episode. Option B, the Heimlich maneuver using chest thrusts, can potentially harm the gravid uterus. Option D, calling 911 immediately before providing assistance, can lead to a delay in addressing the immediate choking emergency.

2. A male client with cirrhosis has jaundice and pruritus. He tells the nurse that he has been soaking in hot baths at night with no relief of his discomfort. What action should the nurse take?

• A. Explain that the symptoms are caused by liver damage and can be managed
• B. Obtain a PRN prescription for an analgesic that the client can use for symptom relief
• C. Encourage the client to use cooler water and apply oil-based lotion after soaking
• D. Suggest that the client take brief showers and apply oil-based lotion after showering

Correct answer: D

Rationale: Cooler water and oil-based lotion can help relieve pruritus and improve comfort in clients with cirrhosis experiencing jaundice and pruritus. Hot baths can exacerbate itching, so it is important to suggest cooler showers instead. Choice A is incorrect because symptoms like pruritus can be managed. Choice B is not the most appropriate initial intervention for pruritus related to liver disease. Choice C suggests the use of calamine lotion, which may not be as effective as oil-based lotion for relieving pruritus in this case.

3. A client prescribed warfarin is being taught about dietary modifications by a nurse. Which statement by the client indicates understanding of the teaching?

• A. ''I need to avoid foods high in vitamin C.''
• B. ''I should eat a consistent amount of vitamin K each day.''
• C. ''I can eat as many leafy greens as I want.''
• D. ''I should not worry about any changes in my diet.''

Correct answer: B

Rationale: The correct answer is B. Consistency in vitamin K intake is crucial for clients on warfarin to maintain stable anticoagulation levels. Option A is incorrect as vitamin C does not directly interact with warfarin. Option C is incorrect because although leafy greens are high in vitamin K, excessive consumption can affect warfarin's effectiveness. Option D is incorrect as any changes in diet, particularly in vitamin K intake, can impact the efficacy of warfarin.

4. During the administration of albuterol per nebulizer, the client complains of shakiness. The client’s vital signs are heart rate 120 beats/minute, respirations 20 breaths/minute, blood pressure 140/80. What action should the nurse take?

• A. Administer an anxiolytic
• B. Obtain a 12-lead electrocardiogram
• C. Stop the albuterol administration and restart in 30 minutes
• D. Educate the client about the side effects of albuterol

Correct answer: D

Rationale: Shakiness is a known side effect of albuterol, which can often be managed without the need for additional medications. Educating the client about the potential side effects of albuterol, including shakiness, helps them understand what to expect and how to manage these effects. Administering an anxiolytic (Choice A) is not indicated as shakiness related to albuterol is not a sign of anxiety. Obtaining a 12-lead electrocardiogram (Choice B) is not necessary based on the client's presentation of shakiness and vital signs. Stopping the albuterol administration and restarting in 30 minutes (Choice C) may not be necessary since shakiness is a common side effect that can often be managed without interrupting the treatment.

5. The nurse is demonstrating wound care to a client following abdominal surgery. In what order should the nurse teach the technique?

• A. Remove old dressing using clean gloves. Discard gloves with old dressing
• B. Moisten sterile gauze with normal saline. Clean wound from least contaminated area to most contaminated area
• C. Apply sterile gauze dressing to wound area
• D. Secure dressing with tape

Correct answer: A

Rationale: The correct order ensures proper aseptic technique and wound care to prevent infection. The first step is to remove the old dressing using clean gloves to prevent contamination. Discarding the gloves with the old dressing helps maintain cleanliness. Choices B, C, and D are incorrect because cleaning the wound, applying a new dressing, and securing it should come after removing the old dressing to maintain asepsis and prevent infection.

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