Nursing Elites

1. The client reports nausea and constipation. Which of the following would be the priority nursing action?

• A. Collect a stool sample
• B. Complete an abdominal assessment
• C. Administer an anti-nausea medication
• D. Notify the physician

Correct answer: B

Rationale: The priority nursing action when a client reports symptoms like nausea and constipation is to complete an abdominal assessment. Assessment is crucial as it involves the systematic collection of data to understand the client's condition. By assessing the abdomen, the nurse can gather essential information to make a nursing diagnosis and develop a care plan. Collecting a stool sample (Choice A) may be necessary but comes after the assessment to confirm findings. Administering an anti-nausea medication (Choice C) addresses symptoms but does not address the underlying cause without a thorough assessment. Notifying the physician (Choice D) should come after the assessment to provide a complete picture of the client's condition.

2. While caring for Mr. Charles Y., you see a notation on the nursing care plan that states, 'remind the patient to use the incentive spirometer tid.' This patient will be reminded at which of the following times?

• A. 10:00 AM
• B. 10 am and 2 pm
• C. 10 am, 2 pm, and 6 pm
• D. 10 am, 2 pm, 6 pm, and 10 pm

Correct answer: C

Rationale: The abbreviation 'tid' stands for 'ter in die,' which means three times a day. In this case, the patient should be reminded to use the incentive spirometer at 10 am, 2 pm, and 6 pm. Option A, '10 am,' is too infrequent for tid dosing. Option B, '10 am and 2 pm,' is missing the third reminder at 6 pm. Option D, '10 am, 2 pm, 6 pm, and 10 pm,' includes an additional time that is not part of the standard tid dosing schedule.

3. An adult patient is at the clinic for a physical examination. The patient states that they are feeling 'very anxious' about the physical examination. What steps can the nurse take to make the patient more comfortable?

• A. Appear unhurried and confident when examining the patient.
• B. Leave the room when the patient undresses unless they need assistance.
• C. Ask the patient to change into an examining gown and to leave their undergarments on.
• D. Measure vital signs at the beginning of the examination to gradually accustom the patient.

Correct answer: A

Rationale: To help alleviate the patient's anxiety, the nurse should appear unhurried and confident during the examination. This can make the patient feel more at ease and reassured. It is important for the nurse to respect the patient's privacy by leaving the room while the patient changes unless assistance is needed. The patient should be instructed to change into an examining gown while leaving their undergarments on, providing a sense of comfort and familiarity. Additionally, measuring vital signs at the beginning of the examination can help gradually acclimate the patient to the process, making it less overwhelming. Therefore, the correct answer is to appear unhurried and confident when examining the patient. Choices B, C, and D are incorrect because they do not directly address the patient's anxiety or provide comfort in the same way as the correct answer.

4. The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP is observed?

• A. UAP splint the patient's chest during coughing.
• B. UAP assist the patient to ambulate to the bathroom.
• C. UAP help the patient to a bedside chair for meals.
• D. UAP lower the head of the patient's bed to 15 degrees.

Correct answer: D

Rationale: The correct action for the nurse to intervene in is when the UAP lowers the head of the patient's bed to 15 degrees. This position can decrease ventilation in a patient with pneumonia, potentially worsening their condition. Choices B and C involve assisting the patient with activities of daily living and promoting mobility, which are appropriate for the patient's care. Choice A, splinting the patient's chest during coughing, can help the patient manage coughing effectively, which is also appropriate for a patient with pneumonia.

5. After change-of-shift report, which patient should the nurse assess first?

• A. 72-year-old with cor pulmonale who has 4+ bilateral edema in his legs and feet
• B. 28-year-old with a history of a lung transplant and a temperature of 101 F (38.3 C)
• C. 40-year-old with a pleural effusion who is complaining of severe stabbing chest pain
• D. 64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion

Correct answer: D

Rationale: The patient with lung cancer and tracheal deviation after a subclavian catheter insertion should be assessed first. Tracheal deviation can indicate tension pneumothorax, a life-threatening condition that requires immediate intervention to prevent inadequate cardiac output or hypoxemia. While the other patients also need assessment, the potential for tension pneumothorax in the patient with tracheal deviation necessitates urgent attention to prevent complications.

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