Nursing Elites

1. What is the priority nursing action during the immediate postoperative period for a client who just underwent a coronary artery bypass graft?

• A. Monitor for signs of infection
• B. Ensure the client is pain-free
• C. Assess for bleeding and arrhythmias
• D. Maintain a patent airway

Correct answer: D

Rationale: Maintaining a patent airway is the priority nursing action during the immediate postoperative period for a client who just underwent a coronary artery bypass graft. This is crucial to ensure adequate oxygenation, especially in the early recovery phase. Monitoring for signs of infection, ensuring the client is pain-free, and assessing for bleeding and arrhythmias are important aspects of postoperative care but maintaining a clear airway takes precedence in this scenario to prevent hypoxia and respiratory compromise. In the immediate postoperative period, maintaining a patent airway is essential to prevent complications such as airway obstruction, hypoxia, and respiratory distress, which are critical in ensuring the client's safety and recovery.

2. A client admitted to the hospital with advanced liver failure related to chronic alcoholism is exhibiting ascites and edema. Which pathophysiological mechanisms should the nurse identify as responsible for the third spacing symptoms? (Select all that apply.)

• A. Portal hypertension.
• B. Sodium and water retention.
• C. Decreased serum albumin.
• D. All of the above

Correct answer: D

Rationale: In advanced liver failure related to chronic alcoholism, ascites and edema occur due to multiple pathophysiological mechanisms. Portal hypertension contributes to the development of ascites by increasing pressure in the portal venous system. Sodium and water retention exacerbate fluid accumulation in the third space. Decreased serum albumin levels lead to reduced oncotic pressure, contributing to the movement of fluid into the interstitial spaces. Abnormal protein metabolism further disrupts fluid balance. Therefore, all of the options (A, B, and C) are correct in this scenario, making choice D the correct answer. Choices A, B, and C alone do not fully explain the comprehensive pathophysiological mechanisms involved in the development of ascites and edema in this clinical context.

3. During a routine prenatal visit, a nurse measures a client’s fundal height. The client is 26 weeks pregnant. What should the fundal height be?

• A. Approximately 26 cm
• B. Between 24 to 28 cm
• C. Above the umbilicus by two finger widths
• D. Below the xiphoid process

Correct answer: B

Rationale: The correct answer is B: Between 24 to 28 cm. Fundal height corresponds to the weeks of gestation, so at 26 weeks of pregnancy, the fundal height should range between 24 to 28 cm. This measurement is a quick way to assess fetal growth and amniotic fluid volume. Choice A is incorrect because fundal height may vary and not always match the exact weeks of pregnancy. Choice C, measuring above the umbilicus by two finger widths, is not a standard method for fundal height measurement. Choice D, below the xiphoid process, is too high and not relevant for assessing fundal height during pregnancy.

4. A client with pneumonia is experiencing difficulty expectorating thick secretions. What intervention should the nurse implement to assist the client?

• A. Administer antibiotics as prescribed
• B. Perform chest physiotherapy
• C. Encourage increased fluid intake
• D. Provide humidified oxygen

Correct answer: C

Rationale: The correct intervention for a client experiencing difficulty expectorating thick secretions due to pneumonia is to encourage increased fluid intake. Increasing fluid intake helps to thin secretions, making them easier to expectorate. Administering antibiotics (Choice A) is important in treating pneumonia but does not directly address the issue of thick secretions. Chest physiotherapy (Choice B) may help in some cases, but increasing fluid intake is a more straightforward and effective intervention. Providing humidified oxygen (Choice D) can help with oxygenation but does not directly address the problem of thick secretions.

5. A client with chronic obstructive pulmonary disease (COPD) is struggling to breathe. What should the nurse do first?

• A. Increase the oxygen flow rate according to the prescription
• B. Encourage the client to perform pursed-lip breathing
• C. Prepare for emergency intubation
• D. Assess the client's oxygen saturation and breath sounds

Correct answer: D

Rationale: The correct first action for a nurse when a client with COPD is struggling to breathe is to assess the client's oxygen saturation and breath sounds. This initial assessment is crucial in determining the severity of the client's condition and the appropriate intervention. Increasing the oxygen flow rate without proper assessment can potentially be harmful, as COPD clients have a risk of retaining carbon dioxide. Encouraging pursed-lip breathing can be beneficial but should come after assessing the client's current status. Emergency intubation is a drastic measure and should only be considered after a comprehensive assessment indicates the need for it.

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