Nursing Elites

1. A nurse is caring for a client who has a pulmonary embolism. The nurse should identify the effectiveness of the treatment by assessing which of the following?

• A. A chest x-ray reveals increased density in all lung fields
• B. The client reports feeling less anxious
• C. Diminished breath sounds are auscultated unilaterally
• D. ABG results include pH 7.48, PaO2 77 mm Hg, and PaCO2 47 mm Hg

Correct answer: B

Rationale: The correct answer is B. Client-reported improvement in anxiety is an indication of effective treatment for pulmonary embolism. Choice A is incorrect as increased density in all lung fields on a chest x-ray may indicate complications or lack of improvement. Choice C is incorrect as diminished breath sounds auscultated unilaterally may suggest a localized lung issue and not necessarily reflect the effectiveness of treatment for a pulmonary embolism. Choice D is incorrect as the ABG results provided do not specifically indicate the effectiveness of treatment for a pulmonary embolism.

2. A nurse is developing a care plan for a client who has paraplegia and has an area of nonblanchable erythema over the ischium. Which intervention should the nurse include?

• A. Place the client upright on a donut-shaped cushion.
• B. Teach the client to shift his weight every 15 minutes while sitting.
• C. Turn and reposition the client every 3 hours.
• D. Assess pressure points every 24 hours.

Correct answer: B

Rationale: The correct intervention for a client with nonblanchable erythema over the ischium is to teach the client to shift his weight every 15 minutes while sitting. This action helps relieve pressure on the affected area and prevents further skin breakdown. Placing the client upright on a donut-shaped cushion (Choice A) may not address the need for frequent weight shifts. Turning and repositioning the client every 3 hours (Choice C) is important for overall skin health but may not provide adequate relief for the specific area of nonblanchable erythema. Assessing pressure points every 24 hours (Choice D) is not frequent enough to prevent worsening of the skin condition in this case.

3. What is the priority nursing action for a patient experiencing an acute asthma attack?

• A. Administer bronchodilators
• B. Administer corticosteroids
• C. Provide supplemental oxygen
• D. Start IV fluids

Correct answer: A

Rationale: The correct answer is to administer bronchodilators as the priority nursing action for a patient experiencing an acute asthma attack. Bronchodilators help open the airways and improve airflow, which is crucial in managing the acute respiratory distress in asthma. Corticosteroids may be used subsequently to reduce inflammation, but in the acute phase, bronchodilators take precedence. Providing supplemental oxygen is important but may not address the underlying bronchoconstriction characteristic of an asthma attack. Starting IV fluids is not a priority in managing an acute asthma attack unless indicated for specific reasons such as dehydration.

4. A client expresses fear of surgery. Which response should the nurse make?

• A. Explain the risks of the surgery in detail.
• B. Tell the client that many clients feel anxious before surgery.
• C. Reassure the client that the surgical team is highly experienced.
• D. Acknowledge the client's feelings and ask open-ended questions.

Correct answer: D

Rationale: When a client expresses fear of surgery, it is essential for the nurse to acknowledge their feelings and ask open-ended questions. This response shows empathy, validates the client's emotions, and encourages them to express their concerns further. Explaining the risks of the surgery in detail (Choice A) may increase the client's anxiety. Simply stating that many clients feel anxious before surgery (Choice B) does not address the client's specific fears. While reassuring the client about the surgical team's experience (Choice C) is important, it may not directly alleviate the client's fear.

5. A nurse is preparing to administer vancomycin IV to a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take?

• A. Administer the medication over 60 minutes
• B. Monitor the client's blood glucose level during administration
• C. Infuse the medication rapidly to reduce the risk of infection
• D. Administer the medication using a filter needle

Correct answer: A

Rationale: The correct action the nurse should take is to administer the medication over 60 minutes. This is important because administering vancomycin over 60 minutes helps prevent red man syndrome, a reaction that can occur with rapid infusion. Monitoring the client's blood glucose level (Choice B) is unrelated to vancomycin administration. Infusing the medication rapidly (Choice C) is incorrect and can lead to adverse reactions. Administering the medication using a filter needle (Choice D) is unnecessary for vancomycin administration.

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