Nursing Elites

1. A nurse is in an acute care facility, caring for a client who is postop following abdominal surgery. Which behavior should the nurse identify as increasing the client's risk for constipation?

• A. Increased fiber intake
• B. Suppression of the urge to defecate
• C. Ambulation twice a day
• D. Daily laxative use

Correct answer: B

Rationale: The correct answer is B: 'Suppression of the urge to defecate.' Suppressing the urge to defecate can lead to constipation, especially in postoperative clients. It is essential to encourage clients to respond to the urge to defecate to prevent constipation. Increased fiber intake (Choice A) is beneficial for preventing constipation. Ambulation (Choice C) helps promote bowel motility and can reduce the risk of constipation. Daily laxative use (Choice D) may contribute to laxative dependence but is not the behavior most directly associated with increasing the risk of constipation in this scenario.

2. A nurse is performing a focused assessment on a client who has a history of COPD and is experiencing dyspnea. Which of the findings should the nurse expect?

• A. Flaring of the nostrils
• B. Normal respiratory rate
• C. Clear lung sounds
• D. Decreased work of breathing

Correct answer: A

Rationale: Flaring of the nostrils indicates increased respiratory effort, common in clients with dyspnea due to COPD. In COPD, the airways are narrowed, causing difficulty in breathing, leading to increased work of breathing. Normal respiratory rate and clear lung sounds are less likely findings in a client with COPD experiencing dyspnea. Decreased work of breathing is not expected in this situation as COPD typically results in increased work of breathing.

3. A client is receiving IV moderate sedation with midazolam and has a respiratory rate of 9/min. What should the nurse do?

• A. Place the client in a prone position
• B. Implement positive pressure ventilation
• C. Perform nasopharyngeal suctioning
• D. Administer flumazenil

Correct answer: D

Rationale: The correct answer is D: Administer flumazenil. Flumazenil is the reversal agent for midazolam, a benzodiazepine, and should be administered to counteract respiratory depression. Placing the client in a prone position (choice A) could further compromise their breathing. Implementing positive pressure ventilation (choice B) is not indicated as the first step when dealing with respiratory depression due to sedation. Performing nasopharyngeal suctioning (choice C) is not appropriate in this situation where the client is experiencing respiratory depression due to medication sedation.

4. A nurse is caring for a client who has a prescription for enalapril. The nurse should monitor the client for which of the following adverse effects of this medication?

• A. Bradycardia
• B. Hyperkalemia
• C. Hyperglycemia
• D. Tinnitus

Correct answer: B

Rationale: The correct answer is B: Hyperkalemia. Enalapril, an ACE inhibitor, can lead to hyperkalemia by reducing aldosterone levels, which results in potassium retention. Bradycardia (Choice A) is not a common adverse effect of enalapril. Hyperglycemia (Choice C) and tinnitus (Choice D) are also not typically associated with enalapril use.

5. A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take first?

• A. Administer an antihistamine prior to transfusion.
• B. Check the client’s vital signs.
• C. Verify the client’s identification with another nurse.
• D. Prime the IV tubing with normal saline.

Correct answer: C

Rationale: The correct first action the nurse should take when preparing to administer packed RBCs to a client is to verify the client’s identification with another nurse. This is crucial to ensure that the correct blood product is administered to the correct client, minimizing the risk of a transfusion reaction. Administering an antihistamine prior to transfusion (Choice A) is not the first priority and is not a standard practice. While checking the client’s vital signs (Choice B) is important, verifying the client’s identification takes precedence to prevent a critical error. Priming the IV tubing with normal saline (Choice D) is a necessary step in the process but should occur after verifying the client's identity.

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