Nursing Elites

1. A nurse is preparing to administer an IV bolus of 0.9% sodium chloride to a client who is dehydrated. Which of the following actions should the nurse take?

• A. Administer the solution slowly over 24 hours
• B. Assess the client's lung sounds before administration
• C. Change the IV tubing every 12 hours
• D. Flush the IV line with 2 mL of heparin every 4 hours

Correct answer: B

Rationale: The correct action for the nurse to take is to assess the client's lung sounds before administering IV fluids. This is crucial to identify any signs of fluid overload, such as crackles or wheezes. Administering the solution slowly over 24 hours (choice A) is not appropriate for an IV bolus, which is a rapid infusion. Changing the IV tubing every 12 hours (choice C) is a standard practice for preventing infection but is not directly related to administering an IV bolus. Flushing the IV line with heparin every 4 hours (choice D) is a maintenance practice to prevent clot formation in the line, not specifically related to administering an IV bolus.

2. A nurse is caring for a client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse implement?

• A. Use a donut-shaped cushion for sitting
• B. Turn the client every 4 hours
• C. Elevate the head of the bed to 45 degrees
• D. Massage reddened areas to increase circulation

Correct answer: C

Rationale: Elevating the head of the bed reduces pressure on bony prominences, which helps prevent pressure ulcers.

3. A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD) and is experiencing dyspnea. Which of the following actions should the nurse take?

• A. Encourage the client to take deep breaths.
• B. Place the client in a high-Fowler's position.
• C. Administer a bronchodilator.
• D. Administer oxygen at 6 L/min via face mask.

Correct answer: B

Rationale: The correct answer is to place the client in a high-Fowler's position. This position helps improve breathing by expanding the lungs and aiding in better oxygenation. Encouraging the client to take deep breaths may not be effective in managing dyspnea in COPD as it can lead to fatigue. Administering a bronchodilator may be necessary but placing the client in a high-Fowler's position should be the priority. Administering oxygen at 6 L/min via face mask may also be needed, but positioning is the initial intervention to optimize respiratory function.

4. A nurse is caring for a client who is 4 hours postoperative following an open cholecystectomy. Which of the following actions should the nurse take?

• A. Monitor the client's urinary output.
• B. Assist the client to splint the incision with a pillow when coughing.
• C. Provide the client with a clear liquid diet.
• D. Encourage the client to ambulate in the hallway.

Correct answer: B

Rationale: Assisting the client to splint the incision with a pillow while coughing is the correct action in this scenario. This intervention helps reduce pain and prevent wound dehiscence, which is the partial or complete separation of the layers of a surgical wound. Monitoring urinary output is important but not the priority at this immediate postoperative stage. Providing a clear liquid diet may be indicated later but is not the most immediate concern. Encouraging ambulation is beneficial for preventing complications like deep vein thrombosis, but splinting the incision is more crucial at this early postoperative period.

5. A client has a new prescription for levothyroxine. Which of the following statements should the nurse include?

• A. Take this medication with food to prevent nausea.
• B. Take this medication in the morning to prevent insomnia.
• C. You should store this medication in the refrigerator.
• D. Take this medication with a full glass of water before breakfast.

Correct answer: D

Rationale: The correct statement the nurse should include is to take levothyroxine with a full glass of water before breakfast. This helps improve absorption and prevents gastrointestinal side effects. Choice A is incorrect because levothyroxine should be taken on an empty stomach. Choice B is incorrect as insomnia is not a common side effect of levothyroxine. Choice C is also incorrect as levothyroxine does not need to be refrigerated.

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