Nursing Elites

1. A nurse is caring for a client prescribed sildenafil for erectile dysfunction. Which of the following should the nurse monitor?

• A. Blood pressure
• B. Heart rate
• C. Temperature
• D. Respiratory rate

Correct answer: A

Rationale: The correct answer is A: Blood pressure. Sildenafil, a medication for erectile dysfunction, can cause changes in blood pressure. The nurse should monitor for hypotension as a potential side effect. Monitoring heart rate (choice B) is not a priority when administering sildenafil unless there are pre-existing heart conditions. Temperature (choice C) and respiratory rate (choice D) are typically not directly affected by sildenafil administration, making them less relevant for monitoring in this case.

2. A nurse is planning care for a client who has a chest tube. Which of the following actions should the nurse take to ensure proper functioning of the chest tube?

• A. Clamp the chest tube intermittently.
• B. Keep the drainage system below chest level.
• C. Empty the drainage chamber every 4 hours.
• D. Apply sterile gauze around the insertion site daily.

Correct answer: B

Rationale: To ensure proper functioning of a chest tube, the nurse should keep the drainage system below chest level. This position allows for proper drainage by gravity and prevents backflow into the pleural space. Clamping the chest tube intermittently can lead to a buildup of pressure and should be avoided. Emptying the drainage chamber every 4 hours is important but not directly related to maintaining the chest tube's function. Applying sterile gauze around the insertion site daily is essential for infection prevention but does not specifically ensure the proper functioning of the chest tube.

3. A nurse is teaching a client about the use of a metered-dose inhaler (MDI). Which instruction should the nurse include in the teaching?

• A. Inhale the medication deeply for 3-5 seconds
• B. Exhale forcefully before inhaling
• C. Shake the MDI vigorously before use
• D. Hold the mouthpiece 2.5-5 cm (1-2 in) in front of the mouth

Correct answer: A

Rationale: Corrected Rationale: Inhaling the medication deeply for 3-5 seconds and holding the breath for 10 seconds after inhalation ensures effective medication delivery to the lungs. Choice A is the correct instruction for the use of a metered-dose inhaler (MDI). Choice B, exhaling forcefully before inhaling, is incorrect as it can lead to decreased medication delivery. Choice C, shaking the MDI vigorously before use, is also incorrect as excessive shaking can cause the medication to clump. Choice D, holding the mouthpiece 2.5-5 cm (1-2 in) in front of the mouth, is not recommended as it may lead to improper inhalation technique.

4. A nurse is sitting with the partner of a client who recently died. Which action should the nurse take to facilitate mourning?

• A. Offer advice on coping strategies
• B. Encourage the partner to ask for help when needed
• C. Discuss the importance of grieving alone
• D. Suggest the partner avoid talking about the loss

Correct answer: B

Rationale: Encouraging the partner to ask for help when needed is the most appropriate action for the nurse to facilitate mourning. Grieving is a challenging process, and individuals may require support from others to cope effectively. Offering advice on coping strategies, discussing the importance of grieving alone, or suggesting avoiding talking about the loss could hinder the partner's mourning process by isolating them or suppressing their feelings.

5. A client receiving opiates for pain management was initially sedated but is no longer sedated after three days. What action should the nurse take?

• A. Initiate additional non-pharmacological pain management techniques.
• B. Notify the provider that a dosage adjustment is needed.
• C. No action is needed at this time.
• D. Contact the provider to request an alternate method of pain management.

Correct answer: C

Rationale: The correct answer is C: No action is needed at this time. Sedation from opiates commonly decreases as the body adjusts to the medication. It is a positive sign that the sedation has resolved, indicating the client is tolerating the current dosage well. Initiating additional non-pharmacological pain management techniques (Choice A) is unnecessary since the current pain management regimen is effective. Notifying the provider for a dosage adjustment (Choice B) is premature and not indicated when the sedation has resolved. Contacting the provider to request an alternate method of pain management (Choice D) is excessive and not warranted in this situation where the client is no longer sedated and the current pain management plan is effective.

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