Nursing Elites

1. A post-operative client develops a sudden onset of chest pain and dyspnea. The nurse suspects a pulmonary embolism (PE). What is the priority nursing action?

• A. Administer oxygen via face mask.
• B. Elevate the client's legs.
• C. Prepare the client for immediate surgery.
• D. Notify the healthcare provider immediately.

Correct answer: A

Rationale: Administering oxygen via face mask is the priority nursing action in a post-operative client suspected of a pulmonary embolism. This intervention helps ensure adequate oxygenation while further assessments and interventions are initiated. Elevating the client's legs is not indicated for a suspected pulmonary embolism; it is more appropriate for conditions like shock. Immediate surgery is not the priority in this situation as the client is experiencing acute symptoms requiring prompt intervention. While notifying the healthcare provider is important, the immediate focus should be on providing oxygen to the client to support respiratory function.

2. A client post-thoracotomy is complaining of severe pain with deep breathing and coughing. What should the nurse encourage the client to do to manage the pain and prevent respiratory complications?

• A. Hold a pillow against the chest while coughing (splinting).
• B. Take shallow breaths to avoid pain.
• C. Increase the dose of pain medication.
• D. Avoid deep breathing exercises.

Correct answer: A

Rationale: Splinting the chest with a pillow helps manage pain during deep breathing and coughing, which is essential to prevent respiratory complications such as atelectasis or pneumonia after thoracic surgery. Holding a pillow against the chest while coughing (splinting) supports the incision site and reduces the pain associated with deep breathing and coughing. Encouraging shallow breaths (Choice B) can lead to respiratory complications due to inadequate lung expansion. Increasing pain medication (Choice C) should be done based on healthcare provider orders and not solely for this situation. Avoiding deep breathing exercises (Choice D) can worsen respiratory function and increase the risk of complications.

3. Thirty minutes after receiving IV morphine, a postoperative client continues to rate pain as 7 on a 10-point scale. Which action should the PN implement first?

• A. Call healthcare provider to request a different analgesic
• B. Determine when morphine can be given again
• C. Implement complementary pain relief methods
• D. Observe dressing to determine the presence of bleeding

Correct answer: C

Rationale: The most appropriate action for the PN to implement first is to implement complementary pain relief methods. This includes repositioning the client, applying heat or cold packs, or using relaxation techniques. These strategies can provide additional pain relief before the next dose of medication is due or before seeking further instructions from the healthcare provider. Calling the healthcare provider immediately to request a different analgesic (Choice A) may not be necessary at this moment since other non-pharmacological methods can be attempted first. Determining when morphine can be given again (Choice B) is important but addressing the client's immediate pain relief takes precedence. Observing the dressing for bleeding (Choice D) is important but not the first priority when the client is experiencing unrelieved pain.

4. A client post-lobectomy is placed on mechanical ventilation. The nurse notices the client is fighting the ventilator. What should the nurse do first?

• A. Increase the sedation as prescribed.
• B. Manually ventilate the client using an ambu bag.
• C. Check the ventilator settings and alarms.
• D. Suction the client’s airway.

Correct answer: C

Rationale: The correct first action for the nurse to take when a client is fighting the ventilator is to check the ventilator settings and alarms. This step is crucial to ensure that the ventilator is functioning correctly and providing the necessary support to the client. Increasing sedation (Choice A) should only be considered after confirming that the ventilator settings are appropriate. While manually ventilating the client (Choice B) may be required in some cases, it is not the initial action to take. Suctioning the client's airway (Choice D) is not the priority in this situation, where the primary concern is addressing the client's struggle with the ventilator.

5. A 12-year-old child is receiving a blood transfusion via an infusion pump and begins to complain of 'itchy' skin 15 minutes after the unit of blood is started. The child appears flushed. What action should the nurse take first?

• A. Apply lotion to the skin
• B. Stop the transfusion
• C. Inspect the infusion site
• D. Obtain the vital signs

Correct answer: B

Rationale: Stopping the transfusion immediately is crucial when signs of a transfusion reaction, such as itching and flushing, occur. This action is taken to prevent further exposure to the potentially harmful transfused blood. Applying lotion to the skin, inspecting the infusion site, or obtaining vital signs can be important but are secondary to stopping the transfusion to ensure the safety of the child. Applying lotion may not address the underlying issue of a possible transfusion reaction. Inspecting the infusion site and obtaining vital signs can be done after stopping the transfusion, as patient safety is the top priority in this situation.

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