Nursing Elites

1. The healthcare provider is assessing a client who has just undergone a thoracentesis. Which finding should be reported immediately?

• A. Diminished breath sounds on the affected side.
• B. Pain at the procedure site.
• C. Blood-tinged sputum.
• D. Shortness of breath.

Correct answer: D

Rationale: Shortness of breath should be reported immediately as it may indicate a pneumothorax, a potential complication of thoracentesis. Diminished breath sounds on the affected side, pain at the procedure site, and blood-tinged sputum are common findings post-thoracentesis and do not necessarily indicate immediate complications like a pneumothorax.

2. The healthcare provider is preparing to administer a 1.2mL injection to a 4-year-old. Which is the best site to administer an IM injection?

• A. Vastus Lateralis
• B. Radial artery
• C. Dorsogluteal
• D. Rectus femoris

Correct answer: A

Rationale: The correct answer is A, Vastus Lateralis. The vastus lateralis site is recommended for IM injections in small children due to its large muscle mass, making it suitable for injections in pediatric patients. Choices B, C, and D are incorrect. The radial artery is not a site for IM injections; it is a site for arterial puncture. The dorsogluteal site is not recommended for children due to potential risks, such as injury to the sciatic nerve. The rectus femoris is not typically used for IM injections in children, as other sites like the vastus lateralis are more commonly preferred.

3. A client with asthma is prescribed an albuterol inhaler. Which instruction should the nurse provide?

• A. Use the inhaler only during an asthma attack
• B. Rinse your mouth after using the inhaler
• C. Shake the inhaler before each use
• D. Exhale fully before inhaling the medication

Correct answer: C

Rationale: The correct instruction for the nurse to provide is to shake the inhaler before each use. Shaking the inhaler ensures proper mixing of the medication before administration, which is crucial for its effectiveness. Choice A is incorrect because albuterol inhalers are often used as a preventive measure, not just during asthma attacks. Choice B is a good practice to prevent oral fungal infections associated with inhaled corticosteroids, not typically with albuterol. Choice D is important for proper inhaler technique, but the primary step before inhaling is shaking the inhaler to ensure the medication is well mixed.

4. The nurse is preparing a client for discharge after a major surgical procedure. What is the priority instruction to include in the discharge teaching?

• A. Signs of infection to monitor for
• B. Pain management techniques
• C. Activity restrictions and safety measures
• D. All of the above

Correct answer: D

Rationale: The correct answer is D: All of the above. Providing comprehensive discharge instructions covering signs of infection to monitor for, pain management techniques, activity restrictions, and safety measures is crucial after a major surgical procedure. Each of these components plays a vital role in the client's recovery and well-being. It is important for the client to understand how to identify signs of infection, manage pain effectively, and adhere to activity restrictions to prevent complications and ensure a smooth recovery process. While each instruction is important on its own, combining all aspects into the discharge teaching ensures that the client has a holistic understanding of their post-operative care, empowering them to take charge of their health and know when to seek further assistance if needed. Choices A, B, and C are essential components of discharge teaching and should all be included to provide the client with comprehensive care instructions.

5. While caring for a client who is being mechanically ventilated, the nurse responds to a high-pressure alarm on the ventilator. Which assessment finding warrants immediate intervention by the nurse?

• A. Endotracheal cuff pressure greater than 25 cm H2O.
• B. Decreased lung compliance during ventilation.
• C. Bilateral crackles with increased secretions.
• D. Restless client who is biting the endotracheal tube.

Correct answer: D

Rationale: A restless client biting the endotracheal tube can increase airway resistance, triggering the high-pressure alarm and indicating a need for immediate intervention. This behavior can lead to complications such as dislodgement of the tube or airway obstruction. Endotracheal cuff pressure greater than 25 cm H2O, decreased lung compliance, and bilateral crackles with increased secretions are important assessments but do not directly address the urgent need to intervene when a high-pressure alarm is triggered.

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