Nursing Elites

1. A client is experiencing acute bronchospasm. What is the nurse's priority intervention?

• A. Administer a nebulizer treatment of albuterol.
• B. Start an IV infusion of normal saline.
• C. Administer oxygen at 4L/min via nasal cannula.
• D. Position the client in a high Fowler's position.

Correct answer: A

Rationale: The correct answer is to administer a nebulizer treatment of albuterol. In acute bronchospasm, the priority intervention is to deliver a bronchodilator like albuterol to open the airways and improve breathing. Starting an IV infusion of normal saline (Choice B) may be necessary but not the priority in this situation. Administering oxygen at 4L/min via nasal cannula (Choice C) is important but not the first intervention for bronchospasm. Positioning the client in a high Fowler's position (Choice D) can help with breathing but is not the priority over administering a bronchodilator.

2. A client with a 42-week gestation refuses induction. What is the most important action the nurse should take?

• A. Discuss alternative ways to support the client's birth plan.
• B. Explain the risks of induction after 42 weeks.
• C. Ask the healthcare provider to discuss the situation with the client.
• D. Discuss the characteristics of labor with oxytocin vs. natural labor.

Correct answer: A

Rationale: The most important action for the nurse in this situation is to discuss alternative ways to support the client's birth plan. By doing so, the nurse can ensure that the client feels heard, respected, and supported in their decision-making process. While explaining the risks of induction after 42 weeks (Choice B) may be important, it is secondary to supporting the client's autonomy and preferences. Asking the healthcare provider to discuss the situation with the client (Choice C) may delay crucial communication and support that the nurse can provide. Discussing the characteristics of labor with oxytocin vs. natural labor (Choice D) is not the priority when the client has refused induction, as the focus should be on respecting their decision and exploring other options for support.

3. While auscultating heart sounds, the nurse hears a swishing sound. How should this sound be documented?

• A. Heart murmur.
• B. Murmur.
• C. S3 sound.
• D. S4 sound.

Correct answer: B

Rationale: The correct answer is B: 'Murmur.' A murmur is a swishing sound heard during auscultation, typically caused by turbulent blood flow through the heart or valves. Choices C and D, 'S3 sound' and 'S4 sound,' refer to specific heart sounds associated with different cardiac conditions, not the general description of a swishing sound. Choice A, 'Heart murmur,' is redundant as 'murmur' alone is sufficient to describe the swishing sound heard.

4. Which activity is most important for a client recovering from a hip replacement to avoid during the first few weeks of recovery?

• A. Sitting in a chair for short periods
• B. Crossing the legs while sitting
• C. Walking with assistance
• D. Performing light stretching exercises

Correct answer: B

Rationale: The correct answer is B: Crossing the legs while sitting. Cross-leg position after a hip replacement can significantly increase the risk of hip dislocation. During the first few weeks of recovery, it is crucial for clients to avoid crossing their legs to protect the new joint. Choices A, C, and D are not as critical during the initial recovery phase. Sitting in a chair for short periods, walking with assistance, and performing light stretching exercises are generally encouraged activities that can help in the recovery process without posing a significant risk of complications like hip dislocation.

5. The nurse is caring for a group of clients with the help of a PN. Which nursing actions should the nurse assign to the PN?

• A. All of the above
• B. Administer a dose of insulin per sliding scale for a client with Type 2 DM
• C. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty
• D. Perform daily surgical dressing change for a client who had an abdominal hysterectomy

Correct answer: A

Rationale: All of these tasks fall within the PN's scope of practice, which includes performing surgical dressing changes, taking postoperative vital signs, and administering insulin under supervision. The RN can delegate these tasks to the PN safely. Choice A is the correct answer because all the tasks mentioned are appropriate for delegation to a PN. Choice B should not be assigned to a PN as only RNs should administer insulin. Choice C is suitable for delegation to a PN as obtaining vital signs falls within their scope of practice. Choice D is also appropriate for delegation to a PN as performing surgical dressing changes is within their scope of practice.

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