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. Which of the following procedures always requires surgical asepsis?

• A. Vaginal instillation of conjugated estrogen
• B. Urinary catheterization
• C. Nasogastric tube insertion
• D. Colostomy irrigation

Correct answer: B

Rationale: Surgical asepsis, which involves maintaining a sterile field and preventing contamination in a surgical setting, is required for urinary catheterization as it involves entering a sterile body cavity. Vaginal instillation of conjugated estrogen, nasogastric tube insertion, and colostomy irrigation do not always require surgical asepsis as they involve different levels of sterility and infection control measures.

3. A healthcare provider is reviewing the laboratory report of a client who has been taking lithium carbonate for the past 12 months. The provider notes a lithium level of 0.8 mEq/L. Which of the following orders from the provider should the healthcare provider expect?

• A. Withhold the next dose
• B. Increase the dosage
• C. Discontinue the medication
• D. Administer the medication

Correct answer: D

Rationale: A lithium level of 0.8 mEq/L falls within the therapeutic range for maintaining the drug's effectiveness while minimizing toxicity. Therefore, the appropriate action would be to continue administering the medication as prescribed by the healthcare provider to maintain the therapeutic effect for the client.

4. A nurse manager is reviewing documentation with a newly licensed nurse. Which of the following notations by the newly licensed nurse indicates an understanding of the teaching?

• A. ''OOB with assistance for breakfast''
• B. ''Given 2 mg MSO4 IM for report of pain''
• C. ''Dressing changed qd''
• D. ''Administered 8 units of regular insulin subcutaneously''

Correct answer: D

Rationale: The correct answer demonstrates proper documentation by specifying the action taken ('Administered'), the dose ('8 units'), the medication ('regular insulin'), and the route of administration ('subcutaneously'). This notation ensures clarity and accuracy in recording the nursing intervention, aligning with best practices in documentation.

5. A client who is at 38 weeks gestation, is in active labor, and has ruptured membranes is being cared for by a nurse. What action should the nurse take?

• A. Insert an indwelling urinary catheter
• B. Apply fetal heart rate monitor
• C. Initiate fundal massage
• D. Initiate an oxytocin IV infusion

Correct answer: B

Rationale: When caring for a client in active labor with ruptured membranes, the priority action for the nurse is to apply a fetal heart rate monitor. This helps monitor the well-being of the fetus during labor and delivery, enabling timely interventions if any fetal distress is detected. Inserting an indwelling urinary catheter may be required in some cases, but it is not the priority in the given scenario. Fundal massage is typically done after delivery to help the uterus contract and prevent postpartum hemorrhage. Initiating an oxytocin IV infusion may be indicated to augment labor, but it is not the initial action needed in this situation.

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