Nursing Elites

1. A client has had a cast applied, and a nurse is providing care. Which of the following actions should the nurse take first?

• A. Place an ice pack over the cast.
• B. Palpate the pulse distal to the cast.
• C. Teach the client to keep the cast clean and dry.
• D. Position the casted extremity on a pillow.

Correct answer: B

Rationale: When caring for a client with a newly applied cast, the nurse's priority should be to assess the circulation by palpating the pulse distal to the cast. This is crucial to ensure there is no compromise in blood flow, which could lead to serious complications. Placing an ice pack over the cast, teaching the client about cast care, and positioning the casted extremity on a pillow are important interventions but should follow the assessment of circulation.

2. A client is scheduled for a thoracentesis. Which of the following supplies should NOT be in the client's room?

• A. Oxygen equipment
• B. Incentive spirometer
• C. Pulse oximeter
• D. Sterile dressing

Correct answer: B

Rationale: During a thoracentesis procedure, the focus is on draining fluid or air from the pleural space. An incentive spirometer, which helps improve lung function, is not a necessary supply for this specific procedure. Oxygen equipment, pulse oximeter for monitoring oxygen saturation levels, and sterile dressing for wound care may be needed during or after the procedure.

3. When planning care for a client with severe acute respiratory distress syndrome (SARS), which of the following actions should not be included in the care plan?

• A. Administer antibiotics
• B. Provide supplemental oxygen
• C. Administer antiviral medications
• D. Administer bronchodilators

Correct answer: A

Rationale: Severe acute respiratory distress syndrome (SARS) is caused by a virus, not bacteria, and antibiotics are ineffective against viral infections. Therefore, administering antibiotics would not be appropriate in the care plan for a client with SARS. The priority interventions for SARS include providing supplemental oxygen to improve oxygenation, administering antiviral medications to target the viral infection, and using bronchodilators to help with bronchospasm or airway constriction. Antibiotics are not indicated unless there is a secondary bacterial infection present.

4. Which natural body defense plays an active role in preventing infection?

• A. Yawning
• B. Body hair
• C. Hiccupping
• D. Rapid eye movements

Correct answer: B

Rationale: Body hair plays an active role in preventing infection by acting as a filter to block pathogens. It helps to prevent harmful substances from entering the body through the skin, providing a physical barrier against potential infections.

5. A healthcare provider is performing a gastric lavage for a client who has upper gastrointestinal bleeding. Which of the following actions should the healthcare provider take?

• A. Instill 500 ml of solution through the NG tube.
• B. Insert a large-bore NG tube.
• C. Use a cold irrigation solution.
• D. Instruct the client to lie on their right side.

Correct answer: B

Rationale: During a gastric lavage procedure for upper gastrointestinal bleeding, inserting a large-bore NG tube is essential to effectively remove gastric contents and blood. This tube allows for efficient irrigation and suction, aiding in the removal of harmful substances from the stomach. Instilling a large volume of solution or using a cold irrigation solution can lead to complications such as fluid overload or hypothermia. Instructing the client to lie on their right side is not directly related to the gastric lavage procedure.

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