Nursing Elites

1. A nurse is caring for a client who has a prescription for furosemide. Which of the following findings should the nurse identify as an indication that the medication is effective?

• A. Weight loss of 0.5 kg (1.1 lb) in 24 hours.
• B. Increased urinary output.
• C. Blood pressure of 118/78 mm Hg.
• D. Decreased peripheral edema.

Correct answer: A

Rationale: The correct answer is A. Weight loss of 0.5 kg (1.1 lb) in 24 hours is an indication that furosemide is effectively reducing fluid retention. This medication works by promoting diuresis, resulting in increased urine output, which could lead to weight loss. While increased urinary output (choice B) is a common effect of furosemide, weight loss is a more specific indicator of its effectiveness. Blood pressure (choice C) and decreased peripheral edema (choice D) can be influenced by various factors and are not direct indicators of furosemide's effectiveness in reducing fluid retention.

2. What is the priority nursing action for a patient with respiratory distress?

• A. Administer oxygen
• B. Reposition the patient
• C. Administer bronchodilators
• D. Provide chest physiotherapy

Correct answer: A

Rationale: The priority nursing action for a patient with respiratory distress is to administer oxygen. Oxygen therapy is crucial in improving oxygenation levels and relieving respiratory distress, making it the top priority intervention. Repositioning the patient, administering bronchodilators, or providing chest physiotherapy may be necessary interventions depending on the underlying cause, but ensuring adequate oxygen supply should take precedence in addressing respiratory distress.

3. A client has a chest tube connected to a water-seal drainage system. Which of the following actions should be taken?

• A. Clamp the chest tube during ambulation
• B. Keep the collection chamber below the level of the chest
• C. Add sterile water to the water-seal chamber
• D. Empty the collection chamber every 12 hours

Correct answer: C

Rationale: The correct action for the nurse to take when caring for a client with a chest tube connected to a water-seal drainage system is to add sterile water to the water-seal chamber. This is necessary to maintain the correct water level for proper chest tube function. Clamping the chest tube during ambulation (Choice A) is incorrect as it can lead to complications by obstructing drainage. Keeping the collection chamber below the level of the chest (Choice B) is incorrect because it should be kept below the chest to facilitate drainage. Emptying the collection chamber every 12 hours (Choice D) is incorrect as it should be emptied whenever it reaches the fill line or as per facility policy, not on a fixed time schedule.

4. A nurse is assessing a client who is 1 hour postoperative following a hysterectomy. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 78/min.
• B. Blood pressure of 120/80 mm Hg.
• C. Oxygen saturation of 94%.
• D. Respiratory rate of 16/min.

Correct answer: A

Rationale: A heart rate of 78/min is within the normal range; however, postoperative patients require close monitoring for any signs of complications. While the heart rate is normal, other critical findings such as increased pain, excessive bleeding, or other concerning symptoms may need immediate attention. Choices B, C, and D all indicate normal postoperative vital signs and oxygen saturation levels, which do not raise immediate concerns requiring reporting to the provider.

5. A client with bipolar disorder and experiencing mania is under the care of a nurse. Which intervention should the nurse include in the plan?

• A. Encourage the client to spend time in the day room.
• B. Withdraw the client's TV privileges if they do not attend group therapy.
• C. Encourage the client to take frequent rest periods.
• D. Place the client in seclusion when they exhibit signs of anxiety.

Correct answer: C

Rationale: Encouraging the client to take frequent rest periods is an appropriate intervention for managing mania in a client with bipolar disorder. During a manic episode, individuals often have increased energy levels, decreased need for sleep, and may engage in high-risk behaviors. Encouraging regular rest periods can help reduce stimulation and promote relaxation, which may assist in stabilizing mood. Choices A and B are not as effective in managing manic symptoms, as they do not directly address the client's need for rest and relaxation. Choice D is inappropriate because placing the client in seclusion can increase feelings of anxiety and agitation, worsening the manic episode.

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