Nursing Elites

1. The healthcare provider is assessing a client who has just received anesthesia. What is the most critical finding to report to the healthcare provider?

• A. Client reports dizziness
• B. Client has a drop in blood pressure
• C. Client experiences mild nausea
• D. Client reports dry mouth

Correct answer: B

Rationale: A significant drop in blood pressure following anesthesia could indicate a serious reaction, such as hypovolemia or anesthetic-induced hypotension. This requires immediate medical attention, while other symptoms like dizziness, mild nausea, and dry mouth are more common and less critical. Dizziness could be expected due to the effects of anesthesia, mild nausea is a common side effect, and dry mouth is a known effect of anesthesia as well.

2. A client receiving codeine for pain every 4 to 6 hours over 4 days. Which assessment should the nurse perform before administering the next dose?

• A. Auscultate the bowel sounds.
• B. Palpate the ankles for edema.
• C. Observe the skin for bruising.
• D. Measure the body temperature.

Correct answer: A

Rationale: The correct answer is A: Auscultate the bowel sounds. Codeine is known to cause constipation, so it is essential to assess bowel sounds before administering another dose to monitor for potential constipation or bowel motility issues. Palpating the ankles for edema (Choice B) is not directly related to codeine use or its side effects. Observing the skin for bruising (Choice C) is important but not specifically associated with codeine administration. Measuring body temperature (Choice D) is not a priority assessment related to codeine use; monitoring for constipation is more critical in this case.

3. The nurse is administering an intradermal injection for a tuberculosis skin test. Which technique should the nurse use?

• A. Use a 25-gauge needle at a 90-degree angle
• B. Use a 27-gauge needle at a 15-degree angle
• C. Use a 22-gauge needle at a 45-degree angle
• D. Use a 20-gauge needle at a 90-degree angle

Correct answer: B

Rationale: An intradermal injection for a tuberculosis skin test should be administered using a 27-gauge needle at a 15-degree angle. This technique ensures that the medication is delivered into the dermis layer of the skin. Choice A is incorrect because a 25-gauge needle is too large for an intradermal injection. Choice C is incorrect as a 22-gauge needle is also too large and the angle is too steep for an intradermal injection. Choice D is incorrect as a 20-gauge needle is too large for an intradermal injection, and a 90-degree angle would not deliver the medication accurately into the dermis.

4. The nurse is planning care for a client with a venous leg ulcer. Which intervention should the nurse include in the plan of care to promote healing?

• A. Apply compression therapy to the affected leg
• B. Keep the affected leg in a dependent position
• C. Massage the area surrounding the ulcer
• D. Encourage the client to elevate the leg for 2 hours daily

Correct answer: A

Rationale: Compression therapy is essential for managing venous leg ulcers as it helps improve venous return, reduces edema, and promotes healing. By applying compression therapy to the affected leg, the nurse can assist in enhancing circulation, reducing swelling, and aiding in the healing process. Keeping the affected leg in a dependent position can worsen venous insufficiency. Massaging the area surrounding the ulcer is contraindicated as it can cause further damage and delay healing. While encouraging the client to elevate the leg is beneficial, it is not as effective as compression therapy for promoting healing in venous leg ulcers.

5. A client with a history of chronic kidney disease presents with increased swelling and shortness of breath. What is the nurse's priority action?

• A. Administer oxygen at 2 liters per nasal cannula.
• B. Administer a diuretic as prescribed.
• C. Monitor the client's vital signs.
• D. Reposition the client to improve lung expansion.

Correct answer: B

Rationale: The correct answer is to administer a diuretic as prescribed. In a client with chronic kidney disease experiencing increased swelling and shortness of breath, the priority action is to address fluid retention. Administering a diuretic helps reduce fluid overload, alleviate symptoms, and prevent complications associated with fluid buildup. Option A is not the priority in this situation as addressing fluid retention takes precedence over providing oxygen. While monitoring vital signs is important, it is secondary to addressing the underlying cause of symptoms. Repositioning the client may help with comfort but does not directly address the fluid overload seen in chronic kidney disease.

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