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 client is receiving intermittent tube feedings and is at risk for aspiration. What should the nurse identify as a risk factor?

• A. A residual of 65mL 1 hour postprandial.
• B. History of gastroesophageal reflux disease.
• C. Receiving a high-osmolarity formula.
• D. Receiving a feeding in a supine position.

Correct answer: B

Rationale: The correct answer is B: History of gastroesophageal reflux disease. Gastroesophageal reflux disease increases the risk of aspiration due to the potential for regurgitation of stomach contents into the esophagus and airways. Choices A, C, and D are not directly related to an increased risk of aspiration. A residual of 65mL 1 hour postprandial may indicate delayed gastric emptying but is not a direct risk factor for aspiration. Receiving a high-osmolarity formula or receiving a feeding in a supine position are not specific risk factors for aspiration unless they contribute to reflux or other related issues.

3. A nurse is planning care for a client who has chronic obstructive pulmonary disease (COPD). Which of the following interventions should the nurse include?

• A. Encourage the client to take deep breaths.
• B. Administer oxygen as needed.
• C. Teach the client pursed-lip breathing.
• D. Limit the client's fluid intake.

Correct answer: C

Rationale: The correct intervention for a client with COPD is to teach pursed-lip breathing. This technique helps improve oxygenation and reduce dyspnea by promoting better air exchange in the lungs. Encouraging deep breaths may not be suitable for clients with COPD as it can lead to air trapping. Administering oxygen is important in COPD, but teaching pursed-lip breathing is a more direct intervention to help the client manage their condition. Limiting fluid intake is not a standard intervention for COPD and may not be relevant to improving respiratory status.

4. What is the best intervention for a patient with suspected deep vein thrombosis (DVT)?

• A. Administer anticoagulants
• B. Apply compression stockings
• C. Encourage ambulation
• D. Monitor oxygen saturation

Correct answer: A

Rationale: The best intervention for a patient with suspected deep vein thrombosis (DVT) is to administer anticoagulants. Anticoagulants help prevent further clot formation and reduce the risk of complications such as pulmonary embolism. Applying compression stockings can help manage symptoms but does not address the underlying issue of clot formation. Encouraging ambulation is beneficial for overall circulation but may not be sufficient to treat DVT. Monitoring oxygen saturation is important, but it is not the primary intervention for suspected DVT.

5. A nurse is teaching a newly licensed nurse about ergonomic principles. Which of the following actions by the nurse indicates an understanding of the teaching?

• A. Stands with feet shoulder-width apart when lifting a client up in bed.
• B. Raises the client's knees before pulling the client up in bed.
• C. Uses a mechanical lift to move a client from bed to chair.
• D. Places a gait belt around the client's waist before assisting the client to stand.

Correct answer: C

Rationale: Using a mechanical lift is an appropriate ergonomic technique as it reduces the risk of injury to both the nurse and the client by promoting safe client handling practices. Choice A is incorrect as standing with feet shoulder-width apart provides better balance and stability during lifting. Choice B is incorrect as raising the client's knees is not directly related to ergonomic principles. Choice D is incorrect as placing a gait belt around the client's waist is a safety measure but does not specifically demonstrate an understanding of ergonomic principles.

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