Nursing Elites

1. A client is admitted for first and second degree burns on the face, neck, anterior chest, and hands. The nurse's priority should be

• A. Cover the areas with dry sterile dressings
• B. Assess for dyspnea or stridor
• C. Initiate intravenous therapy
• D. Administer pain medication

Correct answer: B

Rationale: The correct answer is to assess for dyspnea or stridor. In burn cases involving the face, neck, or chest, there is a risk of airway compromise due to swelling. Dyspnea (difficulty breathing) or stridor (noisy breathing) can indicate airway obstruction or respiratory distress, which requires immediate intervention. Covering the burns with dry sterile dressings (choice A) can be important but ensuring airway patency takes precedence. Initiating intravenous therapy (choice C) may be necessary but not the priority over assessing the airway. Administering pain medication (choice D) is important for comfort but should come after ensuring the airway is clear and breathing is adequate.

2. A nurse is reinforcing discharge teaching with a client who has acute pancreatitis and a prescription for fat-soluble vitamin supplements. Which of the following supplements should the nurse include in the teaching?

• A. Vitamin A
• B. Vitamin B1
• C. Vitamin C
• D. Vitamin B12

Correct answer: A

Rationale: The correct answer is Vitamin A. Fat-soluble vitamins essential for patients with pancreatitis include A, D, E, and K, aiding in proper nutrient absorption. Vitamin B1 (Choice B), also known as thiamine, is a water-soluble vitamin and not a fat-soluble one. Vitamin C (Choice C) is another water-soluble vitamin and not a fat-soluble one. Vitamin B12 (Choice D) is also a water-soluble vitamin and not one of the fat-soluble vitamins crucial for patients with pancreatitis.

3. The health care provider order reads 'aspirate nasogastric feeding (NG) tube every 4 hours and check pH of aspirate.' The pH of the aspirate is 10. Which action should the nurse take?

• A. Hold the tube feeding and notify the provider
• B. Administer the tube feeding as scheduled
• C. Irrigate the tube with diet cola soda
• D. Apply intermittent suction to the feeding tube

Correct answer: A

Rationale: A pH of 10 indicates improper placement of the NG tube, requiring notification of the provider and holding the feeding. Choice B is incorrect because administering the tube feeding could lead to complications due to the improper placement. Choice C is incorrect as irrigating the tube with diet cola soda is not a standard practice for addressing this issue. Choice D is incorrect as applying intermittent suction does not address the problem of improper placement indicated by the high pH level.

4. A client with chronic obstructive pulmonary disease (COPD) is experiencing dyspnea. Which of these actions should the nurse perform first?

• A. Administer oxygen therapy
• B. Encourage the client to perform deep breathing exercises
• C. Raise the head of the bed
• D. Check the client's oxygen saturation level

Correct answer: D

Rationale: The correct answer is to check the client's oxygen saturation level first. This action is crucial in assessing the severity of dyspnea and determining the necessity for oxygen therapy. Administering oxygen therapy without knowing the current oxygen saturation level can be inappropriate and potentially harmful. Encouraging deep breathing exercises and raising the head of the bed are important interventions, but assessing the oxygen saturation level takes precedence in managing dyspnea in a client with COPD.

5. A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the health care provider?

• A. Light pink urine
• B. Occasional suprapubic cramping
• C. Minimal drainage into the urinary collection bag
• D. Complaints of the feeling of pulling on the urinary catheter

Correct answer: C

Rationale: In a client with an indwelling catheter and continuous bladder irrigation post TURP, minimal drainage into the urinary collection bag should be reported to the health care provider. This finding could indicate a blockage in the catheter or a complication that requires immediate attention. Light pink urine (choice A) is expected due to bladder irrigation. Occasional suprapubic cramping (choice B) is common post-TURP. Complaints of the feeling of pulling on the urinary catheter (choice D) may indicate discomfort but do not suggest an urgent issue like a potential blockage.

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