Nursing Elites

1. A client with a history of chronic back pain is prescribed oxycodone for pain management. What is the most important instruction the nurse should provide?

• A. Take the medication with food to reduce stomach upset
• B. Avoid operating heavy machinery while taking this medication
• C. Increase physical activity to enhance pain relief
• D. Report any signs of respiratory depression immediately

Correct answer: D

Rationale: The correct answer is D: 'Report any signs of respiratory depression immediately.' Respiratory depression is a severe side effect of opioids like oxycodone and can be life-threatening. It is crucial for the nurse to instruct the client to report any signs such as slow or shallow breathing, difficulty breathing, or confusion. Choice A is incorrect as taking oxycodone with or without food does not significantly affect its efficacy. Choice B is incorrect because avoiding driving is important due to the potential impairment caused by oxycodone, but reporting respiratory depression is more critical. Choice C is incorrect as increasing physical activity may not always be suitable for individuals with chronic back pain and is not directly related to preventing respiratory depression.

2. The nurse is assessing a client with a suspected pulmonary embolism (PE). Which symptom is most indicative of this condition?

• A. Bilateral leg swelling.
• B. Sudden onset of chest pain.
• C. Gradual onset of dyspnea.
• D. Decreased breath sounds on auscultation.

Correct answer: C

Rationale: The correct answer is C: 'Gradual onset of dyspnea.' While pulmonary embolism can present with various symptoms, the most common include sudden onset of dyspnea, chest pain (often pleuritic in nature), tachypnea, and tachycardia. Bilateral leg swelling is more commonly associated with conditions like deep vein thrombosis, not pulmonary embolism. Decreased breath sounds on auscultation may be seen in conditions like pneumothorax, not typically in pulmonary embolism. Therefore, the gradual onset of dyspnea is the most indicative symptom of pulmonary embolism in this scenario.

3. A client with diabetes exhibits a blood sugar of 350 mg/dL. What is the nurse's best action?

• A. Administer insulin as prescribed
• B. Provide a carbohydrate-controlled snack
• C. Encourage physical activity
• D. Recheck the blood sugar

Correct answer: A

Rationale: In a client with diabetes presenting with a blood sugar level of 350 mg/dL, the best action for the nurse is to administer insulin as prescribed. High blood sugar levels can lead to complications like diabetic ketoacidosis, making prompt insulin administration crucial to lower the blood glucose level. Providing a carbohydrate-controlled snack would be inappropriate as it may further elevate blood sugar levels. Encouraging physical activity is not advisable when the blood sugar is significantly high, as exercise can raise blood sugar levels. Rechecking the blood sugar is necessary after administering insulin to monitor the response to treatment.

4. A client reports feeling dizzy and light-headed when standing up. What is the nurse's best initial action?

• A. Instruct the client to sit or lie down
• B. Monitor blood pressure and pulse
• C. Administer an anti-dizziness medication
• D. Increase fluid intake

Correct answer: B

Rationale: The correct answer is B: Monitor blood pressure and pulse. When a client reports feeling dizzy and light-headed when standing up, the nurse's best initial action should be to monitor the client's blood pressure and pulse. These symptoms are indicative of orthostatic hypotension, which can be confirmed by changes in blood pressure and pulse when moving from lying to standing positions. Instructing the client to sit or lie down may provide temporary relief but does not address the underlying cause. Administering an anti-dizziness medication should not be the initial action without assessing vital signs first. Increasing fluid intake is important for overall health but is not the priority in this situation where vital sign monitoring is needed to assess for orthostatic hypotension.

5. A client who fell 20 feet from the roof of his home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the intensive care unit (ICU). The nurse observes that the suction control chamber is bubbling at the -10 cm H20 mark, with fluctuation in the water seal, and over the past hour, 75 mL of bright red blood is measured in the collection chamber. Which intervention should the nurse implement?

• A. Increase wall suction to eliminate fluctuation in the water seal.
• B. Give blood from the collection chamber as autotransfusion.
• C. Add sterile water to the suction control chamber.
• D. Manipulate blood in tubing to drain into chamber.

Correct answer: C

Rationale: The correct intervention for the nurse to implement is to add sterile water to the suction control chamber. This action helps maintain the proper functioning of the chest tube system by regulating the negative pressure. Increasing wall suction is not recommended as it could lead to excessive negative pressure. Giving blood from the collection chamber as autotransfusion is inappropriate and poses a risk of complications such as air embolism. Manipulating blood in the tubing is also unsafe as it could introduce air into the system, increasing the risk of complications for the client.

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