Nursing Elites

1. The nurse is caring for a laboring 22-year-old primigravida following administration of regional anesthesia. In planning care for this client, what nursing intervention has the highest priority?

• A. Raising the side rails and placing the call bell within reach
• B. Teaching the client how to push effectively to decrease the length of the second stage of labor
• C. Timing and recording uterine contractions
• D. Positioning the client for proper distribution of anesthesia

Correct answer: A

Rationale: The highest priority nursing intervention for a laboring client following administration of regional anesthesia is to ensure safety by raising the side rails and placing the call bell within reach. This is crucial to prevent falls and to ensure that the client can call for assistance if needed. Teaching the client how to push effectively (Choice B) is important but not the highest priority at this moment. Timing and recording uterine contractions (Choice C) are essential but not as immediate as ensuring safety post-anesthesia. Positioning the client for proper distribution of anesthesia (Choice D) is important but ensuring immediate safety takes precedence in this situation.

2. A client who is 12-hours post-op following a left hip replacement has an indwelling urinary catheter. The nurse determines that the client's urinary output is 60 ml in the past 3 hours. What action should the nurse take first?

• A. Assess the client's vital signs
• B. Irrigate the catheter with 30 ml of sterile normal saline
• C. Notify the healthcare provider
• D. Replace the catheter with a larger size

Correct answer: A

Rationale: In a client post-op with low urinary output, the first action the nurse should take is to assess the client's vital signs. Vital signs can provide valuable information about the client's overall condition, fluid status, and potential complications. Assessing the vital signs can help the nurse to determine if the low urine output is indicative of a larger issue that needs immediate attention. Irrigating the catheter with normal saline may be necessary but should not be the first action without assessing the client. Notifying the healthcare provider should follow assessment if there are concerns. Replacing the catheter with a larger size is not indicated solely based on low urinary output and should not be the first action taken.

3. The nurse is planning discharge teaching for a client with chronic kidney disease. Which information is most important for the nurse to provide this client?

• A. Monitor daily weights
• B. Limit fluid intake to prevent fluid overload
• C. Report any weight gain of more than 2 pounds in a day
• D. Increase protein intake to promote healing

Correct answer: C

Rationale: The most important information for the nurse to provide a client with chronic kidney disease is to report any weight gain of more than 2 pounds in a day. This is crucial because sudden weight gain can indicate fluid retention, which is a common issue in kidney disease. Monitoring daily weights, as in option A, is important but not as critical as reporting sudden weight gain. Option B, limiting fluid intake, is a general recommendation for kidney disease but not the most important aspect in this scenario. Option D, increasing protein intake, is not appropriate as excessive protein intake can be harmful for clients with kidney disease.

4. The nurse is performing a physical assessment of a client with a history of smoking and notes a barrel chest. Which action is most important for the nurse to take next?

• A. Assess the client's oxygen saturation level
• B. Teach the client pursed-lip breathing techniques
• C. Determine the client's history of lung disease
• D. Obtain an arterial blood gas sample

Correct answer: A

Rationale: Corrected Rationale: Assessing the client's oxygen saturation level is crucial when a nurse identifies a barrel chest. A barrel chest is often associated with chronic obstructive pulmonary disease (COPD), which can lead to impaired gas exchange and decreased oxygen saturation. Monitoring the oxygen saturation level will provide immediate information on the client's respiratory status. Teaching pursed-lip breathing techniques, determining lung disease history, and obtaining arterial blood gas samples are important interventions but assessing oxygen saturation takes precedence in this scenario due to its direct impact on the client's respiratory function.

5. While teaching a group of adults about health promotion activities, a nurse identifies a behavior that poses the most significant risk factor for the development of skin cancer. Which behavior should the nurse address?

• A. Consuming a high-fat diet
• B. Using tanning beds
• C. Smoking cigarettes
• D. Drinking alcohol

Correct answer: B

Rationale: Using tanning beds is the most significant risk factor for developing skin cancer. Ultraviolet (UV) radiation from tanning beds damages the skin and increases the risk of skin cancer. Consuming a high-fat diet, smoking cigarettes, and drinking alcohol are unhealthy behaviors but are not directly linked to the development of skin cancer like UV exposure from tanning beds.

Similar Questions