Nursing Elites

1. How should a healthcare provider respond to a patient experiencing a seizure?

• A. Protect the airway and monitor for post-ictal confusion
• B. Administer anticonvulsant medications
• C. Apply restraints to prevent injury
• D. Place the patient in a side-lying position

Correct answer: D

Rationale: When a patient is experiencing a seizure, the immediate priority is to ensure their safety by placing them in a side-lying position. This helps prevent aspiration in case of vomiting and maintains an open airway. Administering anticonvulsant medications is not within the scope of a healthcare provider's immediate response during a seizure. Applying restraints can potentially harm the patient by restricting movement and causing injury. Monitoring for post-ictal confusion is important after the seizure has ended, but the primary concern during the seizure is ensuring the patient's safety.

2. A client who is postoperative following a cholecystectomy has a urine output of 25 mL/hr. Which of the following findings should the nurse report to the provider?

• A. Abdominal pain radiating to the right shoulder.
• B. Absent bowel sounds.
• C. Brown drainage on the surgical dressing.
• D. Urine output of 25 mL/hr.

Correct answer: D

Rationale: A urine output below 30 mL/hr indicates a potential complication, such as hypovolemia or renal impairment, and should be reported. Abdominal pain radiating to the right shoulder can be common after a cholecystectomy due to referred pain from the diaphragm, whereas absent bowel sounds may be expected temporarily postoperatively. Brown drainage on the surgical dressing is typical in the early postoperative period and may represent old blood or other normal discharge.

3. How should a healthcare professional monitor a patient receiving IV potassium?

• A. Monitor ECG for dysrhythmias
• B. Monitor urine output
• C. Monitor serum potassium levels
• D. All of the above

Correct answer: D

Rationale: When a patient is receiving IV potassium, it is crucial to monitor various parameters to ensure patient safety. Monitoring the ECG helps in identifying any potential dysrhythmias that may occur due to potassium imbalances. Monitoring urine output is important as potassium levels can affect renal function. Monitoring serum potassium levels is essential to assess the effectiveness of the IV potassium therapy. Therefore, all the options - monitoring ECG for dysrhythmias, urine output, and serum potassium levels - are necessary when administering IV potassium, making 'All of the above' the correct answer. Choices A, B, and C are not individually sufficient as they each address different aspects of patient monitoring when receiving IV potassium.

4. A nurse is reinforcing teaching about wound care for a client who has a wound requiring irrigation. What is an important instruction?

• A. Wear sterile gloves when applying a new dressing
• B. Cleanse the wound from the center outwards
• C. Keep the wound dry between dressing changes
• D. Apply an antimicrobial ointment to the wound

Correct answer: B

Rationale: The correct answer is to cleanse the wound from the center outwards. This technique helps reduce the risk of contamination by pushing debris away from the wound. Option A, wearing sterile gloves, is important for infection control but not specifically related to wound irrigation. Option C, keeping the wound dry, is not suitable for wound irrigation, which often involves using solutions to clean the wound. Option D, applying an antimicrobial ointment, is not typically done during wound irrigation as the focus is on cleansing the wound.

5. A nurse is assisting with monitoring a client who is at 40 weeks of gestation and is in active labor. The nurse recognizes late decelerations on the fetal monitor tracing. Which of the following actions should the nurse take?

• A. Apply oxygen at 10 L/min via face mask
• B. Position the client on their side
• C. Call for a Cesarean delivery
• D. Administer oxytocin

Correct answer: B

Rationale: Late decelerations indicate uteroplacental insufficiency, and the priority nursing action is to improve placental perfusion. Positioning the client on their side, particularly the left side, can enhance blood flow to the placenta and fetus by reducing pressure on the vena cava and increasing cardiac output. Applying oxygen, although helpful, is not the initial priority in this situation. Calling for a Cesarean delivery is not warranted unless other interventions fail to correct the late decelerations. Administering oxytocin can worsen the condition by increasing uterine contractions, exacerbating fetal distress.

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