Nursing Elites

1. A nurse is planning care for a group of postoperative clients. Which of the following interventions should the nurse identify as the priority?

• A. Administer IV pain medication to a client who reports pain as a 6 on a scale of 0 to 10
• B. Administer oxygen to a client who has an oxygen saturation of 91%
• C. Instruct a client who is 1 hr postoperative about coughing and deep breathing exercises
• D. Initiate an infusion of 0.9% sodium chloride for a client who has just had abdominal surgery

Correct answer: B

Rationale: The priority intervention is administering oxygen. Postoperatively, the client's oxygen saturation should be at or above 95%. Oxygen is essential for tissue perfusion and cellular oxygenation. While managing pain is important, oxygenation takes precedence. Instructing a client about coughing and deep breathing exercises is important for preventing respiratory complications but is not as urgent as addressing low oxygen saturation. Initiating an infusion of 0.9% sodium chloride is a routine postoperative intervention for fluid balance but is not the priority when oxygen saturation is low.

2. What is the priority nursing intervention for a patient admitted with possible acute coronary syndrome?

• A. Administer sublingual nitroglycerin
• B. Obtain cardiac enzymes
• C. Get IV access
• D. Auscultate heart sounds

Correct answer: A

Rationale: The correct answer is to administer sublingual nitroglycerin. This intervention is a priority for a patient with possible acute coronary syndrome because nitroglycerin helps vasodilate coronary arteries, increase blood flow to the heart muscle, relieve chest pain, and reduce cardiac workload. Obtaining cardiac enzymes (choice B) is important for diagnosing myocardial infarction but is not the initial priority. Getting IV access (choice C) is essential for medication administration and fluid resuscitation but is not the priority over administering nitroglycerin. Auscultating heart sounds (choice D) is a routine assessment but does not address the immediate need to relieve chest pain and improve blood flow to the heart in acute coronary syndrome.

3. What is the correct response when a patient receiving an enema reports abdominal cramping?

• A. Lower the height of the enema container
• B. Stop the enema procedure
• C. Remove the enema tubing
• D. Continue the enema at a slower rate

Correct answer: A

Rationale: The correct response when a patient receiving an enema reports abdominal cramping is to lower the height of the enema container. Lowering the height reduces the flow rate, which can help relieve cramping. Stopping the procedure (choice B) may not be necessary if adjusting the height resolves the issue. Removing the enema tubing (choice C) is not the initial step to take when addressing abdominal cramping during an enema. Continuing the enema at a slower rate (choice D) might not be as effective as lowering the height of the container to alleviate cramping.

4. A client at high risk for iron deficiency anemia should increase the consumption of which of the following foods?

• A. Yogurt
• B. Apples
• C. Raisins
• D. Cheddar cheese

Correct answer: C

Rationale: The correct answer is C: Raisins. Raisins are a good source of iron, making them beneficial for a client at high risk for iron deficiency anemia. Yogurt (Choice A), apples (Choice B), and cheddar cheese (Choice D) are not significant sources of iron. Other iron-rich foods include dried fruits, red meat, and green leafy vegetables.

5. What is the preferred electrical intervention for a patient with ventricular tachycardia with a pulse?

• A. Defibrillation
• B. Synchronized cardioversion
• C. Pacing
• D. Medication administration

Correct answer: B

Rationale: Synchronized cardioversion is the preferred electrical intervention for ventricular tachycardia with a pulse. In this scenario, the heart still has an organized rhythm, so synchronized cardioversion is used to deliver a shock at a specific point in the cardiac cycle, aiming to restore a normal rhythm. Defibrillation (Choice A) is used for pulseless ventricular tachycardia or ventricular fibrillation. Pacing (Choice C) may be used for bradycardias or certain types of heart blocks. Medication administration (Choice D) can be considered for stable ventricular tachycardia, but synchronized cardioversion is the primary intervention for ventricular tachycardia with a pulse.

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