Nursing Elites

1. A patient with a history of asthma is admitted with shortness of breath. What is the nurse's priority intervention?

• A. Administer a bronchodilator as prescribed.
• B. Encourage the patient to use an incentive spirometer.
• C. Place the patient in a high Fowler's position.
• D. Monitor the patient's oxygen saturation closely.

Correct answer: A

Rationale: The correct answer is to administer a bronchodilator as prescribed. This intervention is the priority for a patient with asthma experiencing shortness of breath as it helps relax the airways, making breathing easier. Encouraging the use of an incentive spirometer (Choice B) is beneficial for lung expansion but not the priority in this acute situation. Placing the patient in a high Fowler's position (Choice C) can also help with breathing but is not as immediate as administering a bronchodilator. While monitoring the patient's oxygen saturation closely (Choice D) is important, the immediate action to address the breathing difficulty is administering a bronchodilator.

2. What is the priority when assessing a patient for possible deep vein thrombosis (DVT)?

• A. Dorsiflex the foot and check for pain.
• B. Measure the calf circumference of both legs.
• C. Check the skin for signs of redness.
• D. Perform a Doppler ultrasound scan.

Correct answer: B

Rationale: The correct answer is to measure the calf circumference of both legs when assessing a patient for possible DVT. An increase in calf circumference in one leg can indicate the presence of a DVT. Option A is incorrect because dorsiflexing the foot and checking for pain are not primary assessments for DVT. Option C is incorrect as redness of the skin may not always be present in cases of DVT. Option D is incorrect as performing a Doppler ultrasound scan is usually done after clinical assessment and to confirm the diagnosis, not as the initial priority assessment.

3. A patient has difficulty ambulating after surgery. Which action should the nurse take first?

• A. Encourage deep breathing exercises.
• B. Assist the patient in ambulating a short distance.
• C. Call for assistance with ambulation.
• D. Assess the patient's pain level before ambulation.

Correct answer: C

Rationale: The correct first action for the nurse to take when a patient has difficulty ambulating after surgery is to call for assistance with ambulation. This is essential to ensure the safety of the patient and prevent any potential falls or injuries. Encouraging deep breathing exercises (Choice A) may be beneficial but should not be the first priority when the patient is having difficulty walking. Assisting the patient in ambulating a short distance (Choice B) may put both the patient and the nurse at risk if the patient is struggling. Assessing the patient's pain level before ambulation (Choice D) is important but should come after ensuring that the patient can safely ambulate with assistance.

4. A client complains of pain in their leg, and the nurse notes swelling and pallor. What is the priority nursing action?

• A. Administer pain medication.
• B. Elevate the limb and monitor closely.
• C. Encourage movement to reduce swelling.
• D. Notify the provider immediately about the symptoms.

Correct answer: D

Rationale: The correct answer is D: Notify the provider immediately about the symptoms. Swelling and pallor in a limb can be indicative of serious circulatory issues or compartment syndrome. It is crucial to inform the healthcare provider promptly to assess and address the situation. Administering pain medication (choice A) may temporarily alleviate the symptoms but does not address the underlying cause. Elevating the limb and monitoring closely (choice B) can be beneficial but does not replace the need for immediate professional evaluation. Encouraging movement to reduce swelling (choice C) is contraindicated in this scenario as it may worsen the condition if a circulatory issue or compartment syndrome is present.

5. A nurse is providing teaching to a client who has schizophrenia about thioridazine. Which of the following instructions should the nurse include?

• A. Report any sign of infection to the provider immediately
• B. Expect your blood pressure to increase
• C. Easy bruising may occur while taking this medication
• D. Muscle rigidity is an expected adverse effect during the first few days of therapy

Correct answer: A

Rationale: The correct answer is A: 'Report any sign of infection to the provider immediately.' This instruction is essential for clients taking thioridazine or other antipsychotic medications. Thioridazine does not typically affect blood pressure or cause easy bruising. Muscle rigidity is more commonly associated with other antipsychotic medications. Reporting signs of infection promptly is crucial as antipsychotic medications can affect the immune system, making individuals more susceptible to infections. Early detection and treatment of infections help prevent complications and ensure proper medication management.

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