Nursing Elites

1. What is the best intervention for a patient with respiratory distress?

• A. Administer oxygen
• B. Administer bronchodilators
• C. Administer IV fluids
• D. Administer corticosteroids

Correct answer: A

Rationale: The correct answer is to administer oxygen. In respiratory distress, the priority intervention is to improve oxygenation. Administering oxygen helps increase the oxygen levels in the blood, supporting respiratory function. While bronchodilators may be used in specific respiratory conditions like asthma or COPD, they are not the primary intervention for respiratory distress. IV fluids are not indicated as the initial treatment for respiratory distress unless there is an underlying cause such as dehydration. Corticosteroids may be used in certain respiratory conditions to reduce inflammation, but they are not the first-line intervention for acute respiratory distress.

2. While caring for a client receiving an opioid analgesic for pain management, which assessment should the nurse prioritize?

• A. Monitor the client's urinary output.
• B. Check the client's blood pressure.
• C. Assess the client for constipation.
• D. Monitor the client's respiratory rate.

Correct answer: D

Rationale: The correct answer is to monitor the client's respiratory rate. When a client is receiving opioids, the priority assessment is the respiratory rate since opioids can lead to respiratory depression. Monitoring urinary output, blood pressure, and constipation are also important but not the priority in this scenario.

3. A nurse is providing care to a client who has thrombocytopenia. Which of the following actions should the nurse take?

• A. Encourage the client to floss daily.
• B. Remove fresh flowers from the client's room.
• C. Provide the client with a stool softener.
• D. Avoid serving raw vegetables.

Correct answer: C

Rationale: The correct answer is C: Provide the client with a stool softener. Thrombocytopenia is a condition characterized by a low platelet count, which can lead to an increased risk of bleeding. Providing the client with a stool softener helps prevent constipation, reduces the need for straining during bowel movements, and ultimately decreases the risk of bleeding. Choice A is incorrect as flossing daily does not directly address the issue of bleeding risk associated with thrombocytopenia. Choice B is incorrect as removing fresh flowers from the client's room is more related to the risk of infection rather than bleeding in thrombocytopenia. Choice D is incorrect as avoiding serving raw vegetables does not directly impact the risk of bleeding in clients with thrombocytopenia.

4. A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP). Which of the following findings should the nurse report to the provider?

• A. Passing small clots in the urine.
• B. Continuous bladder irrigation.
• C. Red-tinged urine with numerous clots.
• D. Urine output of 50 mL/hr.

Correct answer: C

Rationale: The correct answer is C: Red-tinged urine with numerous clots. This finding should be reported because it indicates excessive bleeding following a TURP procedure. Passing small clots in the urine (choice A) is expected post-TURP. Continuous bladder irrigation (choice B) is a standard procedure after TURP to prevent clot retention. Urine output of 50 mL/hr (choice D) is within the expected range postoperatively and does not indicate a complication.

5. A client is 2 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?

• A. Position the client supine with a pillow between the legs.
• B. Place an abduction pillow between the client's legs.
• C. Place a pillow under the client's knees.
• D. Position the client's legs in adduction.

Correct answer: B

Rationale: After a total hip arthroplasty, it is crucial to prevent hip dislocation. Placing an abduction pillow between the client's legs helps maintain proper alignment of the hip joint and prevents adduction, which could lead to dislocation. Therefore, choice B is the correct action. Choice A is incorrect because positioning the client supine with a pillow between the legs does not provide the necessary abduction to prevent dislocation. Choice C, placing a pillow under the client's knees, does not address the need for abduction. Choice D, positioning the client's legs in adduction, is incorrect as adduction increases the risk of hip dislocation following hip arthroplasty.

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