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. The nurse is monitoring a client who started taking a new medication for rheumatoid arthritis. What is the most important aspect to monitor?

• A. Signs of gastrointestinal bleeding
• B. Liver function tests
• C. Renal function tests
• D. All necessary monitoring based on the medication prescribed

Correct answer: D

Rationale: When a client starts a new medication for rheumatoid arthritis, it is crucial to monitor all necessary aspects based on the specific medication prescribed. Different medications can have varying side effects and impacts on different organ systems. Monitoring all relevant parameters ensures the early detection of any adverse effects and helps to maintain the client's safety. While monitoring for signs of gastrointestinal bleeding, liver function tests, and renal function tests are all important in certain situations, the priority is to conduct comprehensive monitoring based on the medication's known effects.

3. A client reports pain after medication administration. What is the next best step for the nurse?

• A. Reassess the client’s pain
• B. Increase the pain medication dose
• C. Apply a cold compress
• D. Contact the healthcare provider

Correct answer: A

Rationale: The correct answer is to reassess the client’s pain. Reassessment is essential to evaluate the effectiveness of the initial intervention. By reassessing, the nurse can determine if the current pain management plan is adequate or if further interventions are required. Increasing the pain medication dose without reassessment can lead to overmedication and potential adverse effects. Applying a cold compress may not address the underlying cause of the pain and should be based on a proper assessment. Contacting the healthcare provider should be considered if the reassessment indicates a need for further evaluation or intervention beyond the nurse's scope of practice.

4. What safety measure should be implemented when administering chemotherapy?

• A. Use protective gloves and gown
• B. Prepare the medication in a designated area
• C. Administer the medication at the appropriate rate
• D. Verify the two client identifiers

Correct answer: A

Rationale: When administering chemotherapy, it is crucial to use protective gloves and a gown to protect against exposure to hazardous drugs that can be harmful through skin contact. Choice B is incorrect because chemotherapy medication should be prepared in a designated area to prevent contamination and ensure accurate preparation. Choice C is incorrect as chemotherapy should be administered at the appropriate rate to ensure patient safety and avoid adverse effects. Choice D is incorrect as verifying client identifiers is important for medication administration in general but not a specific safety measure related to chemotherapy administration.

5. A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). Which nursing interventions should the nurse include in the plan of care? (Select all that apply.)

• A. Send wound drainage for culture and sensitivity.
• B. Institute contact precautions for staff and visitors.
• C. Use standard precautions and wear a mask.
• D. Monitor the client's white blood cell count.

Correct answer: B

Rationale: When dealing with a client suspected of having MRSA, the nurse should implement contact precautions to prevent the spread of infection. This includes using gowns and gloves, along with following proper hand hygiene practices. Sending wound drainage for culture and sensitivity may be necessary for diagnostic purposes, but it is not directly related to preventing the spread of infection in this case. Using standard precautions and wearing a mask are not sufficient when dealing with MRSA; contact precautions are specifically required to prevent transmission. Monitoring the client's white blood cell count is important in assessing infection status but is not a primary intervention to prevent the spread of MRSA.

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