Nursing Elites

1. The nurse is administering an IV medication to a client with a history of anaphylaxis. Which intervention is most important for the nurse to implement?

• A. Stay with the client throughout the infusion.
• B. Keep emergency resuscitation equipment at the bedside.
• C. Obtain the client's allergy history.
• D. Ask the client about past allergic reactions to medications.

Correct answer: B

Rationale: Keeping emergency resuscitation equipment at the bedside is crucial in case the client experiences anaphylaxis during the infusion. While staying with the client throughout the infusion (Choice A) is important, having immediate access to emergency equipment takes priority in this situation. Obtaining the client's allergy history (Choice C) and asking about past allergic reactions to medications (Choice D) are relevant but do not address the immediate need for emergency intervention in case of anaphylaxis.

2. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which assessment finding requires immediate intervention?

• A. Use of accessory muscles
• B. Oxygen saturation of 90%
• C. Respiratory rate of 24 breaths per minute
• D. Blood pressure of 110/70 mmHg

Correct answer: A

Rationale: The correct answer is A: Use of accessory muscles. This finding indicates increased work of breathing in a client with COPD and may signal respiratory failure, requiring immediate intervention. In COPD, the use of accessory muscles suggests that the client is in distress and struggling to breathe effectively. Oxygen saturation of 90% is within an acceptable range for a client with COPD receiving supplemental oxygen and does not require immediate intervention. A respiratory rate of 24 breaths per minute is slightly elevated but not a critical finding. A blood pressure of 110/70 mmHg is within the normal range for an adult and does not indicate a need for immediate intervention in this scenario.

3. One day after abdominal surgery, an obese client complains of pain and heaviness in the right calf. What action should the nurse implement?

• A. Observe for unilateral swelling
• B. Administer pain medication
• C. Elevate the leg and apply a warm compress
• D. Notify the healthcare provider

Correct answer: A

Rationale: The correct action for the nurse to implement is to observe for unilateral swelling. Unilateral swelling could indicate a deep vein thrombosis (DVT), which is a serious complication that requires immediate assessment. Administering pain medication or applying warm compress may not address the underlying cause of the symptoms. Notifying the healthcare provider should be done after assessing and identifying the issue of unilateral swelling.

4. When administering ceftriaxone sodium (Rocephin) intravenously to a client, what finding requires the most immediate intervention by the nurse?

• A. Stridor
• B. Nausea
• C. Headache
• D. Pruritus

Correct answer: A

Rationale: The correct answer is A: Stridor. Stridor is a high-pitched sound that indicates airway obstruction. When administering ceftriaxone sodium (Rocephin) intravenously, if the client develops stridor, it is a medical emergency requiring immediate intervention to maintain a patent airway. Nausea, headache, and pruritus are important to assess, but they do not pose an immediate threat to the client's airway and would not require the same level of urgent intervention as stridor.

5. A male client with cancer who has lost 10 pounds during the last months tells the nurse that beef, chicken, and eggs, which used to be his favorite foods, now taste 'bitter'. He complains that he simply has no appetite. What action should the nurse implement?

• A. Suggest the use of alternative sources of protein such as dairy products and nuts.
• B. Encourage the client to eat smaller, more frequent meals.
• C. Offer nutritional supplements between meals.
• D. Discuss the possibility of appetite stimulants with the healthcare provider.

Correct answer: A

Rationale: Offering alternative protein sources like dairy products and nuts can help maintain nutrition when the client finds certain foods unpalatable, as in this case where beef, chicken, and eggs taste 'bitter'. Encouraging smaller, more frequent meals may not address the issue of unpalatable foods. Offering nutritional supplements between meals may not specifically address the problem of protein intake. Discussing appetite stimulants should be considered after exploring less invasive options first.

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