Nursing Elites

1. After confirming that liquids are allowed, which assessment action should the nurse consider a priority for a client who is fully awake after a gastroscopy?

• A. Listen to bilateral lung and bowel sounds.
• B. Obtain the client's pulse and blood pressure.
• C. Assist the client to the bathroom to void.
• D. Check the client's gag and swallow reflexes.

Correct answer: D

Rationale: After a gastroscopy, it is crucial for the nurse to prioritize checking the client's gag and swallow reflexes before allowing them to drink anything. This is because the effects of local anesthesia need to dissipate, and the airway's protective reflexes, including the gag and swallow reflexes, must have returned to prevent aspiration. Listening to lung and bowel sounds (Choice A) may be important but does not take precedence over ensuring the client's safety post-gastroscopy. Obtaining the client's pulse and blood pressure (Choice B) is also important but not the priority in this scenario. Assisting the client to the bathroom to void (Choice C) is a routine nursing action and is not directly related to the immediate safety concern of checking the client's gag and swallow reflexes post-gastroscopy.

2. The adult client admitted to the post-anesthesia care unit (PACU) following abdominal surgery has a tympanic temperature of 94.6°F (34.8°C), a pulse rate of 88 beats/minute, a respiratory rate of 14 breaths/minute, and a blood pressure of 94/64 mmHg. Which action should the nurse implement?

• A. Take the client's temperature using another method.
• B. Raise the head of the bed to 60 to 90 degrees.
• C. Ask the client to cough and deep breathe.
• D. Check the blood pressure every five minutes for one hour.

Correct answer: A

Rationale: Taking the client's temperature using another method is the most appropriate action in this situation. A tympanic temperature of 94.6°F (34.8°C) is abnormally low and may not reflect the true core body temperature accurately. By using an alternative method, such as oral or rectal temperature measurement, the nurse can obtain a more reliable temperature reading. Raising the head of the bed (Choice B) is not directly related to addressing the low temperature. Asking the client to cough and deep breathe (Choice C) may be beneficial for respiratory function but does not address the temperature concern. Checking the blood pressure every five minutes for one hour (Choice D) is not the priority when the initial focus should be on accurate temperature assessment.

3. The healthcare provider is unable to palpate the client's left pedal pulses. Which of the following actions should the healthcare provider take next?

• A. Auscultate the pulses with a stethoscope.
• B. Call the physician.
• C. Use a Doppler ultrasound device.
• D. Inspect the lower left extremity.

Correct answer: C

Rationale: When pedal pulses are not palpable, using a Doppler ultrasound device is the appropriate next step to locate the pulse. Auscultating the pulses with a stethoscope (Choice A) is used for assessing blood flow in arteries above the clavicle, not for pedal pulses. Calling the physician (Choice B) may be necessary at a later stage, but initially, using a Doppler ultrasound device to locate the pulse is more appropriate. Inspecting the lower left extremity (Choice D) can provide visual information but will not help in locating the pedal pulses, making it a less suitable option.

4. The best indicator that the client has learned how to give an insulin self-injection correctly is when the client can:

• A. Perform the procedure safely and correctly.
• B. Critique the nurse's performance of the procedure.
• C. Explain all steps of the procedure correctly.
• D. Correctly answer a posttest about the procedure.

Correct answer: A

Rationale: The correct answer is A. Learning is best demonstrated by a change in behavior. A client who can safely and correctly perform the procedure shows they have acquired the skill. Choice B is incorrect because critiquing the nurse's performance does not directly demonstrate the client's ability to perform the procedure. Choice C is incorrect because explaining the steps does not guarantee the client can physically perform the injection. Choice D is incorrect as answering a posttest only assesses theoretical knowledge, not practical application.

5. A marathon runner comes into the clinic and states, 'I have not urinated very much in the last few days.' The nurse notes a heart rate of 110 beats/min and a blood pressure of 86/58 mm Hg. Which action by the nurse is the priority?

• A. Give the client a bottle of water immediately.
• B. Start an intravenous line for fluids.
• C. Teach the client to drink 2 to 3 liters of water daily.
• D. Perform an electrocardiogram.

Correct answer: A

Rationale: The priority action for the nurse is to give the client a bottle of water immediately. The athlete's symptoms of decreased urination, along with a heart rate of 110 beats/min and low blood pressure of 86/58 mm Hg, indicate mild dehydration. Rehydration should begin promptly to address the dehydration. Teaching the client to drink 2 to 3 liters of water daily is a good long-term strategy but not the immediate priority. Starting an intravenous line for fluids may be necessary if oral hydration is insufficient or if the degree of dehydration is severe. Performing an electrocardiogram is not indicated at this time as the priority is addressing the dehydration.

Similar Questions