Nursing Elites

1. The nurse is planning to ambulate a client who has been on bed rest for 24 hours following a Colon Resection. To ambulate this client safely, which intervention should the nurse implement first?

• A. Place non-skid shoes on the client
• B. Show the client how to use the call light
• C. Use a gait belt to support the client
• D. Assist the client to a bedside sitting position

Correct answer: D

Rationale: To ambulate a client safely after a period of bed rest, the nurse should first assist the client to a bedside sitting position. This initial step ensures the client is stable before attempting to stand and walk, reducing the risk of falls and allowing for a gradual adjustment to activity post-bed rest. Placing non-skid shoes, showing how to use the call light, or using a gait belt are important but should come after ensuring the client is safely seated and stable.

2. A client with a severe headache is being assessed by a nurse. What should the nurse do first?

• A. Administer pain relief medication
• B. Check the client's blood pressure
• C. Assess for associated symptoms such as nausea or photophobia
• D. Offer a quiet environment

Correct answer: B

Rationale: When a client presents with a severe headache, the initial action should be to check their blood pressure. This step is crucial as it can help determine if the headache is related to hypertension or other cardiovascular issues. Administering pain relief medication should only be done after assessing the client's vital signs and confirming the cause of the headache. While assessing for associated symptoms like nausea or photophobia is important for a comprehensive evaluation, it should follow checking the blood pressure to address immediate concerns. Offering a quiet environment is indeed beneficial for the client's comfort, but it is not the priority when dealing with a severe headache.

3. 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.

4. The nurse is assessing a client who has been diagnosed with chronic obstructive pulmonary disease (COPD). Which clinical finding is characteristic of this condition?

• A. Pursed-lip breathing
• B. Hyperresonance on percussion
• C. Bradycardia
• D. High-pitched inspiratory crackles

Correct answer: A

Rationale: Pursed-lip breathing is a characteristic finding in clients with COPD. It helps keep the airways open during exhalation, acting as a compensatory mechanism to prevent airway collapse, which is common in COPD. Hyperresonance on percussion is typically found in conditions like emphysema, which is a component of COPD but not characteristic of the overall disease. Bradycardia is not typical in COPD; instead, clients often exhibit tachycardia due to chronic hypoxemia. High-pitched inspiratory crackles are more commonly associated with conditions like pneumonia, not COPD.

5. A client is receiving morphine for pain management. What is the most important assessment for the nurse to perform?

• A. Check the client's respiratory rate
• B. Assess the client's pain level
• C. Monitor the client's blood pressure
• D. Evaluate the client's level of consciousness

Correct answer: A

Rationale: The correct answer is to check the client's respiratory rate. Morphine can lead to respiratory depression, which makes it crucial for the nurse to monitor the client's breathing closely. Assessing the respiratory rate helps in early detection of potential respiratory depression and allows prompt intervention. While assessing pain level (choice B) is important, monitoring the respiratory status takes precedence due to the risk of respiratory depression with morphine. Monitoring blood pressure (choice C) is relevant but not as crucial as assessing respiratory status in a client receiving morphine. Evaluating the level of consciousness (choice D) is also important but does not directly address the immediate risk associated with morphine administration.

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