Nursing Elites

1. A nurse in the PACU is caring for a client who reports nausea. Which of the following actions should the nurse take first?

• A. Turn the client on their side.
• B. Administer an analgesic.
• C. Administer antiemetic.
• D. Monitor the client's vital signs.

Correct answer: A

Rationale: The correct action the nurse should take first when a client reports nausea in the PACU is to turn the client on their side. This action helps prevent aspiration in a client with nausea, reducing the risk of choking or inhaling vomitus. Administering an analgesic (Choice B) is not the priority in this situation unless pain is the primary cause of nausea. While administering an antiemetic (Choice C) can help relieve nausea, it is not the initial action to prevent aspiration. Monitoring the client's vital signs (Choice D) is important but should come after ensuring the client's safety by turning them on their side.

2. A nurse is teaching a newly licensed nurse about ergonomic principles. Which action by the newly licensed nurse indicates an understanding of the teaching?

• A. Stand with feet together when lifting a client.
• B. Raise the client's head of bed before pulling the client up.
• C. Use a mechanical lift to move a client.
• D. Place a gait belt around the client's chest before assisting the client.

Correct answer: C

Rationale: The correct answer is C: 'Use a mechanical lift to move a client.' Using a mechanical lift is an essential ergonomic principle to prevent injury and ensure safe client handling. Choice A is incorrect because standing with feet together when lifting a client can lead to instability and improper weight distribution. Choice B is incorrect as raising the client's head of bed before pulling the client up does not primarily relate to ergonomic principles. Choice D is incorrect because while using a gait belt is important for assisting clients with mobility, it is not specifically related to ergonomic principles for safe handling.

3. What is the best method to manage fluid overload in a patient with heart failure?

• A. Administer diuretics
• B. Provide oral fluids
• C. Increase fluid intake
• D. Provide chest physiotherapy

Correct answer: A

Rationale: Administering diuretics is the best method to manage fluid overload in a patient with heart failure. Diuretics help to remove excess fluid from the body by increasing urine output, thus reducing the fluid volume in the bloodstream and tissues. Providing oral fluids (choice B) or increasing fluid intake (choice C) would exacerbate the fluid overload rather than managing it. Chest physiotherapy (choice D) is not indicated for managing fluid overload in heart failure; it is more commonly used for conditions affecting the lungs or airways.

4. A healthcare professional is reviewing the laboratory results of a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the professional report to the provider?

• A. Blood glucose level of 130 mg/dL
• B. Serum sodium level of 140 mEq/L
• C. Serum potassium level of 3.2 mEq/L
• D. Platelet count of 250,000/mm³

Correct answer: C

Rationale: A serum potassium level of 3.2 mEq/L indicates hypokalemia, a complication that should be reported in clients receiving TPN. Hypokalemia can lead to serious cardiac and neuromuscular complications. The other options are within normal ranges and do not indicate immediate concerns for a client receiving TPN. A blood glucose level of 130 mg/dL, serum sodium level of 140 mEq/L, and platelet count of 250,000/mm³ are all considered normal values and do not require immediate intervention.

5. Which lab value is critical for patients on warfarin therapy?

• A. Monitor INR
• B. Monitor potassium levels
• C. Monitor sodium levels
• D. Monitor platelet count

Correct answer: A

Rationale: The correct answer is to monitor INR levels for patients on warfarin therapy. INR monitoring is essential because it helps assess the clotting tendency of the blood and ensures that patients are within the therapeutic range to prevent both blood clots and excessive bleeding. Monitoring potassium levels (Choice B), sodium levels (Choice C), or platelet count (Choice D) is not specifically required for patients on warfarin therapy and does not directly impact the effectiveness or safety of the medication.

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