Nursing Elites

1. A postoperative client complains of sudden shortness of breath. What should the nurse do first?

• A. Administer oxygen
• B. Call the healthcare provider
• C. Prepare for chest x-ray
• D. Assess the client's lung sounds

Correct answer: D

Rationale: Assessing the client's lung sounds is the most appropriate initial action when a postoperative client complains of sudden shortness of breath. This step helps the nurse evaluate the respiratory status and detect abnormalities such as decreased breath sounds or crackles, which could indicate a serious condition like a pulmonary embolism. Administering oxygen (Choice A) may be necessary but should come after assessing the lung sounds to ensure the appropriate intervention. Calling the healthcare provider (Choice B) or preparing for a chest x-ray (Choice C) can be important subsequent actions based on the findings from the lung sound assessment, but they are not the first priority in this situation.

2. What is the most important action to prevent catheter-associated urinary tract infections (CAUTIs) in a client with an indwelling urinary catheter?

• A. Irrigate the catheter daily.
• B. Change the catheter every 72 hours.
• C. Apply antibiotic ointment at the insertion site.
• D. Ensure the catheter bag is always below bladder level.

Correct answer: D

Rationale: The most crucial action to prevent catheter-associated urinary tract infections (CAUTIs) in a client with an indwelling urinary catheter is to ensure that the catheter bag is always below bladder level. This positioning helps prevent backflow of urine, reducing the risk of CAUTIs. Irrigating the catheter daily (Choice A) is unnecessary and can introduce pathogens. Changing the catheter every 72 hours (Choice B) is not recommended unless clinically indicated to prevent introducing new pathogens. Applying antibiotic ointment at the insertion site (Choice C) is not the most important action to prevent CAUTIs; proper hygiene and maintaining a closed system are more critical.

3. A client with hypothyroidism is taking levothyroxine (Synthroid). Which symptom should prompt the nurse to notify the healthcare provider?

• A. Weight gain
• B. Bradycardia
• C. Nervousness and tremors
• D. Fatigue

Correct answer: C

Rationale: The correct answer is C: Nervousness and tremors. These symptoms may indicate hyperthyroidism resulting from excessive dosing of levothyroxine. Weight gain (Choice A) is a common symptom of hypothyroidism and may indicate undertreatment or inadequate dosing. Bradycardia (Choice B) is a symptom of hypothyroidism and may improve with levothyroxine therapy; it does not typically indicate an urgent need for healthcare provider notification. Fatigue (Choice D) is a symptom of hypothyroidism and can persist even with levothyroxine treatment, so it is not a symptom that would require immediate notification of the healthcare provider.

4. A client with a history of congestive heart failure is prescribed digoxin (Lanoxin). Which assessment is most important for the nurse to obtain before administering this medication?

• A. Blood pressure
• B. Heart rate
• C. Respiratory rate
• D. Oxygen saturation

Correct answer: B

Rationale: The correct answer is B: Heart rate. Before administering digoxin to a client with a history of congestive heart failure, the nurse must assess the client's heart rate. Digoxin can cause bradycardia, so monitoring the heart rate is crucial to prevent potential complications. Assessing blood pressure, respiratory rate, and oxygen saturation are important assessments but are not as directly influenced by digoxin as heart rate is in this scenario. Blood pressure can be affected by various factors, including dehydration or other medications. Respiratory rate and oxygen saturation are more related to respiratory function and gas exchange, which are not the primary concerns when administering digoxin to a client with heart failure.

5. A client is admitted with a diagnosis of myocardial infarction (MI). Which intervention is a priority during the acute phase?

• A. Administer morphine for pain relief
• B. Encourage the client to perform isometric exercises
• C. Position the client flat in bed
• D. Restrict fluid intake

Correct answer: A

Rationale: During the acute phase of a myocardial infarction (MI), the priority intervention is to administer morphine for pain relief. Morphine not only alleviates pain but also reduces myocardial oxygen demand, which is crucial in the management of MI. Encouraging the client to perform isometric exercises (choice B) can increase myocardial oxygen demand and should be avoided during the acute phase. Positioning the client flat in bed (choice C) may worsen symptoms by increasing venous return and workload on the heart. Restricting fluid intake (choice D) is not a priority intervention during the acute phase of MI; maintaining adequate hydration is important for organ perfusion.

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