Nursing Elites

1. A healthcare professional is assessing a client who has a new onset of confusion. Which laboratory value should the professional check first?

• A. Blood glucose level
• B. Serum sodium level
• C. Serum calcium level
• D. Blood urea nitrogen (BUN)

Correct answer: A

Rationale: In a client presenting with a new onset of confusion, checking the blood glucose level first is crucial as hypoglycemia can cause confusion and is easily correctable. Addressing hypoglycemia promptly is essential to prevent further complications.

2. A client who experienced a femur fracture 8 hr ago now reports sudden onset dyspnea and severe chest pain. Which of the following actions should the nurse take first?

• A. Provide high-flow oxygen.
• B. Check the client for a positive Chvostek's sign.
• C. Administer an IV vasopressor medication.
• D. Monitor the client for headache.

Correct answer: A

Rationale: In this situation, the priority action is to provide high-flow oxygen to the client. Sudden onset dyspnea and severe chest pain can be indicative of a pulmonary embolism, which is a life-threatening emergency. Oxygen therapy helps improve oxygenation and stabilizes the client's condition. Checking for Chvostek's sign, administering IV vasopressors, or monitoring for a headache are not the immediate priorities in this critical situation.

3. During assessment, a healthcare provider is evaluating a client with chronic bronchitis. Which of the following percussion sounds should the healthcare provider expect?

• A. Dullness
• B. Resonance
• C. Tympany
• D. Flatness

Correct answer: B

Rationale: In a client with chronic bronchitis, the nurse or healthcare provider would expect to hear resonant sounds upon percussion. Resonance is the normal percussion sound heard over healthy lung tissue. The other options such as dullness, tympany, and flatness are associated with different conditions or abnormalities, not typically expected in chronic bronchitis.

4. A client is 12 hours postoperative following colon resection. Which of the following interventions should the nurse include in the plan to reduce respiratory complications?

• A. Use incentive spirometer every 4 hours while awake.
• B. Initiate ambulation after discontinuing the NG tube.
• C. Maintain a supine position with an abdominal binder.
• D. Splint the incision to support coughing every 2 hours.

Correct answer: D

Rationale: Following a colon resection surgery, it is essential to support the incision site to reduce the risk of respiratory complications. Splinting the incision helps to minimize pain during coughing, aiding in effective clearing of secretions and preventing respiratory problems. This intervention supports the client's respiratory function postoperatively, promoting optimal recovery.

5. A client with tuberculosis is starting combination drug therapy. Which of the following medications should the nurse NOT plan to administer?

• A. Rifampin
• B. Isoniazid
• C. Acyclovir
• D. Pyrazinamide

Correct answer: C

Rationale: Acyclovir is an antiviral medication used to treat herpes virus infections, not tuberculosis. Rifampin, Isoniazid, and Pyrazinamide are all commonly used in the treatment of tuberculosis. Therefore, the nurse should not plan to administer Acyclovir to a client with tuberculosis.

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