Nursing Elites

1. In determining the client position for insertion of an indwelling urinary catheter, it is most important for the nurse to recognize which client condition?

• A. High urinary pH
• B. Abdominal ascites
• C. Orthopnea
• D. Fever

Correct answer: C

Rationale: The correct answer is C: Orthopnea. If the client is orthopneic, the nurse needs to adapt the insertion position that does not place the client in a supine position. This means the head of the bed should be elevated as much as possible to facilitate catheter insertion without compromising the client's breathing. High urinary pH (choice A) is not directly relevant to the insertion position of a urinary catheter. Abdominal ascites (choice B) may impact the procedure due to abdominal distension but is not as crucial as orthopnea. Fever (choice D) does not specifically affect the client's position for urinary catheter insertion.

2. An adolescent's mother calls the clinic because the teen is having recurrent vomiting and has been combative in the last 2 days. The mother states that the teen takes vitamins, calcium, and magnesium supplements along with aspirin. Which nursing intervention has the highest priority?

• A. Advise the mother to withhold all medications by mouth.
• B. Instruct the mother to take the teen to the emergency room.
• C. Recommend that the teen withhold food and fluids for 2 hours.
• D. Suggest that the adolescent breathe slowly and deeply.

Correct answer: B

Rationale: In this scenario, the highest priority nursing intervention is to instruct the mother to take the teen to the emergency room. The symptoms of recurrent vomiting, combative behavior, and the medications (vitamins, calcium, magnesium supplements, and aspirin) taken by the teen suggest a possible overdose or serious adverse reaction. Therefore, immediate medical evaluation is crucial to assess and manage any potential toxicity or adverse effects. Advising to withhold all medications by mouth (Choice A) may delay necessary treatment. Recommending withholding food and fluids for 2 hours (Choice C) may not address the underlying cause of the symptoms. Suggesting slow and deep breathing (Choice D) is not appropriate in this urgent situation requiring immediate medical attention.

3. A client with chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Which assessment finding requires immediate intervention?

• A. Oxygen saturation of 90%
• B. Respiratory rate of 24 breaths per minute
• C. Use of accessory muscles
• D. Inspiratory crackles

Correct answer: C

Rationale: The correct answer is C. The use of accessory muscles indicates increased work of breathing and can signal respiratory failure in a client with COPD. This finding requires immediate intervention to prevent further respiratory compromise. Oxygen saturation of 90% indicates some oxygenation impairment but may not necessitate immediate intervention. A respiratory rate of 24 breaths per minute is slightly elevated but does not indicate immediate respiratory distress. Inspiratory crackles may be present in pneumonia but do not require immediate intervention compared to the increased work of breathing indicated by the use of accessory muscles.

4. The nurse is caring for a client with a history of myocardial infarction who is experiencing chest pain. Which intervention should the nurse implement first?

• A. Administer oxygen therapy as prescribed.
• B. Obtain an electrocardiogram (ECG).
• C. Administer nitroglycerin sublingually as prescribed.
• D. Administer aspirin as prescribed.

Correct answer: A

Rationale: Administering oxygen therapy is the priority intervention in managing chest pain in a client with a history of myocardial infarction. Oxygen helps improve oxygenation to the heart muscle, which is crucial in reducing further damage. Obtaining an electrocardiogram (ECG) is important to assess for changes indicative of myocardial infarction, but providing oxygen takes precedence as it directly addresses the physiological need for oxygen. Administering nitroglycerin and aspirin are important interventions but are typically implemented after oxygen therapy to address vasodilation and antiplatelet effects, respectively.

5. Which nursing intervention is most important when caring for a client with myasthenia gravis?

• A. Encourage the client to rest frequently.
• B. Administer medication 30 minutes before meals.
• C. Maintain a patent airway.
• D. Monitor for signs of respiratory infection.

Correct answer: C

Rationale: Maintaining a patent airway is crucial for clients with myasthenia gravis because muscle weakness can affect the muscles responsible for breathing, potentially leading to respiratory compromise. Encouraging rest, administering medication, and monitoring for respiratory infections are important aspects of care but do not take precedence over ensuring a patent airway for adequate oxygenation.

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