Nursing Elites

1. Prior to a thoracentesis, which of the following actions should the nurse take?

• A. Position the client in an upright position, leaning over the bedside table.
• B. Explain the procedure.
• C. Obtain ABGs.
• D. Administer benzocaine spray.

Correct answer: A

Rationale: Positioning the client in an upright position, leaning over the bedside table helps to facilitate access to the thoracic cavity during the thoracentesis procedure. This position allows for easier identification and access to the insertion site. Explaining the procedure to the client is important, but positioning is the priority. Obtaining ABGs is not directly related to the thoracentesis procedure. Administering benzocaine spray is not a standard practice before a thoracentesis.

2. When preparing an in-service on malpractice issues in nursing, which of the following examples should the nurse include in the teaching?

• A. Leaving a nasogastric tube clamped after administering oral medication
• B. Documenting communication with a provider in the progress notes of the client's medical record
• C. Administering potassium via IV bolus
• D. Placing a yellow bracelet on a client who is at risk for falls

Correct answer: C

Rationale: Administering potassium via IV bolus is a high-risk procedure that requires careful attention and adherence to established protocols to prevent serious complications like cardiac arrest. Errors in administering IV medications, especially potent ones like potassium, can lead to severe harm to the patient and potential legal consequences for the healthcare provider. Therefore, including this example in the in-service on malpractice issues helps emphasize the importance of safe medication administration practices and the potential implications of errors.

3. What is the most appropriate nursing order for a patient who develops dyspnea and shortness of breath?

• A. Maintain the patient on strict bed rest at all times
• B. Maintain the patient in an orthopneic position as needed
• C. Administer high-flow oxygen immediately
• D. Encourage the patient to engage in vigorous physical activity

Correct answer: B

Rationale: Maintaining the patient in an orthopneic position as needed is the most appropriate nursing order for a patient experiencing dyspnea and shortness of breath. This position helps to optimize lung expansion, improve oxygenation, and alleviate breathing difficulties. It is a strategic intervention to enhance respiratory function in patients with respiratory distress. Choice A is incorrect because strict bed rest may not address the underlying respiratory issue effectively. Choice C is premature as administering high-flow oxygen should be based on a comprehensive assessment. Choice D is inappropriate as encouraging vigorous physical activity can exacerbate breathing problems in a patient experiencing dyspnea.

4. Which of the following is not a cause of tachycardia?

• A. Fever
• B. Exercise
• C. Sympathetic nervous system stimulation
• D. Parasympathetic nervous system stimulation

Correct answer: D

Rationale: Tachycardia is an increased heart rate, and it can be caused by various factors such as fever, exercise, and sympathetic nervous system stimulation, all of which tend to increase heart rate. However, parasympathetic nervous system stimulation typically slows the heart rate, making it the exception among the choices provided. Thus, parasympathetic nervous system stimulation is not a cause of tachycardia.

5. When caring for a client in the advanced stage of amyotrophic lateral sclerosis (ALS), which of the following referrals is the nurse's priority?

• A. Psychologist
• B. Social worker
• C. Occupational therapist
• D. Speech-language pathologist

Correct answer: D

Rationale: In the advanced stage of ALS, speech and swallowing difficulties become significant. As a result, the priority referral for the nurse would be a speech-language pathologist. This professional can assist in managing communication challenges and provide strategies to address swallowing issues, ensuring the client's safety and quality of life.

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