Nursing Elites

1. A client has undergone a bronchoscopy, and a nurse is providing care post-procedure. What should the nurse do first?

• A. Monitor the client's oxygen levels
• B. Encourage the client to eat
• C. Check for a gag reflex
• D. Administer IV fluids

Correct answer: C

Rationale: After a bronchoscopy, the nurse's priority is to check for a gag reflex. This action helps assess the client's ability to protect their airway after sedation. Maintaining airway patency is crucial post-procedure. Monitoring oxygen levels is important but ensuring airway protection takes precedence. Encouraging the client to eat and administering IV fluids are essential aspects of care but are not the immediate priority in this situation.

2. A nurse is collecting data from a client who delivered a full-term newborn 16 hours ago. The nurse notes excessive lochia discharge. Which of the following actions should the nurse take first?

• A. Administer pain medication
• B. Perform a fundal massage for the client
• C. Check the baby's heart rate
• D. Apply an ice pack

Correct answer: B

Rationale: The correct action the nurse should take first when noting excessive lochia discharge in a client who delivered a full-term newborn 16 hours ago is to perform a fundal massage. Fundal massage helps stimulate uterine contractions, which in turn reduces bleeding in postpartum clients. Administering pain medication (Choice A) is not the priority in this situation as addressing the excessive lochia discharge is crucial to prevent complications. Checking the baby's heart rate (Choice C) is important but not the first action to manage the mother's condition. Applying an ice pack (Choice D) is not appropriate for managing excessive lochia discharge; fundal massage is the initial intervention to address this issue effectively.

3. A client is scheduled for a lumbar puncture. The nurse should assist the client into which of the following positions?

• A. Supine with head elevated
• B. Lateral recumbent
• C. Prone with arms at sides
• D. Sitting with back rounded

Correct answer: B

Rationale: The correct position for a lumbar puncture is the lateral recumbent position. This position allows the spine to curve naturally, widening the spaces between the vertebrae, making it easier and safer to perform the procedure. Supine with head elevated (Choice A) would not provide the proper positioning for a lumbar puncture as it does not allow for proper access to the lumbar area. Prone with arms at sides (Choice C) would not be suitable as it would not facilitate the procedure. Sitting with back rounded (Choice D) is also incorrect as it does not allow for the proper alignment of the spine needed for a lumbar puncture.

4. A client is prescribed simvastatin. Which instruction should the nurse provide during teaching?

• A. Take this medication in the morning.
• B. Avoid drinking grapefruit juice.
• C. Increase your intake of leafy green vegetables.
• D. Monitor your pulse daily while taking this medication.

Correct answer: B

Rationale: The correct answer is B: 'Avoid drinking grapefruit juice.' Grapefruit juice can increase the risk of toxicity when taken with simvastatin. Instructing the client to avoid grapefruit juice helps prevent this interaction. Choice A is incorrect because the timing of medication administration for simvastatin is usually in the evening. Choice C is unrelated to simvastatin therapy. Choice D is not necessary for monitoring while taking simvastatin.

5. Which of the following interventions should the nurse prioritize for a client with dementia who is at risk of falls?

• A. Use restraints to prevent the client from leaving the bed
• B. Use a bed exit alarm system to notify staff when the client attempts to leave the bed
• C. Encourage frequent ambulation with assistance
• D. Raise all four side rails to prevent falls

Correct answer: B

Rationale: The correct answer is B. Using a bed exit alarm system is a non-restrictive intervention that alerts staff when the client tries to leave the bed, promoting safety and preventing falls. Choice A is incorrect because using restraints can have adverse effects and should be avoided whenever possible. Choice C is not the priority for a client at risk of falls due to dementia as it may increase the risk of falls without proper supervision. Choice D is also not recommended as raising all four side rails can lead to restraint and should be used cautiously, if at all. Therefore, the best option is to use a bed exit alarm system to ensure the client's safety while allowing some freedom of movement.

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