Nursing Elites

1. The nurse plans to administer the rubella vaccine to a postpartum client whose titer is < 1:8 and who is breastfeeding. What information should the nurse provide this client?

• A. The client should bottle feed and pump her breast for 3 days following immunization
• B. The vaccine is given to produce maternal antibodies before lactation occurs
• C. The infant will receive immunization through the mother's breast milk
• D. The client should not get pregnant for 3 months after immunization

Correct answer: D

Rationale: Educating about the waiting period helps prevent possible rubella infection in a subsequent early pregnancy.

2. A client with a diagnosis of chronic obstructive pulmonary disease (COPD) is receiving home oxygen therapy. What is the most important instruction the nurse should provide?

• A. Use oxygen at the highest flow rate tolerated.
• B. Do not smoke while using oxygen.
• C. Avoid wearing the oxygen during physical activity.
• D. Store oxygen tanks in a cool, dark place.

Correct answer: B

Rationale: The most important instruction the nurse should provide to a client with COPD receiving home oxygen therapy is not to smoke while using oxygen. Smoking near oxygen can cause a fire or explosion due to the flammable nature of oxygen. Choice A is incorrect because using oxygen at the highest flow rate tolerated without medical supervision can be harmful. Choice C is the correct answer as wearing oxygen during physical activity can increase the risk of oxygen combustion. Choice D is not the most important instruction; while storing oxygen tanks properly is essential, the immediate safety concern is the risk of fire due to smoking near oxygen.

3. A postoperative client complains of sudden shortness of breath. What should the nurse do first?

• A. Administer oxygen
• B. Call the healthcare provider
• C. Prepare for chest x-ray
• D. Assess the client's lung sounds

Correct answer: D

Rationale: Assessing the client's lung sounds is the most appropriate initial action when a postoperative client complains of sudden shortness of breath. This step helps the nurse evaluate the respiratory status and detect abnormalities such as decreased breath sounds or crackles, which could indicate a serious condition like a pulmonary embolism. Administering oxygen (Choice A) may be necessary but should come after assessing the lung sounds to ensure the appropriate intervention. Calling the healthcare provider (Choice B) or preparing for a chest x-ray (Choice C) can be important subsequent actions based on the findings from the lung sound assessment, but they are not the first priority in this situation.

4. The nurse is assessing an older resident with a history of Benign Prostatic Hypertrophy and identifies a distended bladder. What should the nurse do?

• A. Stand the client to void and run tap water within hearing distance before catheterizing
• B. Straight catheterize and if the residual urine volume is greater than 100 mL, clamp catheter
• C. Catheterize q2h and place in an indwelling catheter at the end of the prescribed 24hr period
• D. Catheterize with an indwelling catheter and if the residual volume is greater than 100 mL, inflate the balloon

Correct answer: D

Rationale: Prompt and appropriate management of urinary retention prevents complications like infection and bladder damage.

5. A nurse is developing a care plan for a client with chronic pain. What interventions should be included to help manage pain?

• A. Administer pain medication around the clock
• B. Teach relaxation techniques
• C. Encourage physical activity
• D. All of the above

Correct answer: D

Rationale: In managing chronic pain, it is essential to employ a multi-faceted approach. Administering pain medication around the clock helps maintain consistent pain relief. Teaching relaxation techniques such as deep breathing or guided imagery can help reduce muscle tension and promote relaxation, which can alleviate pain. Encouraging physical activity, tailored to the client's abilities, can help improve overall physical functioning and reduce pain perception. Therefore, combining all these interventions (pain medication, relaxation techniques, and physical activity) provides a comprehensive approach to pain management, addressing different aspects of the client's experience with chronic pain. This holistic approach is more effective than using a single intervention alone, making 'All of the above' the correct choice.

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