Nursing Elites

1. What is the first priority for a patient in respiratory distress?

• A. Administer oxygen
• B. Assess airway patency
• C. Monitor oxygen saturation
• D. Call for assistance

Correct answer: A

Rationale: The correct answer is to administer oxygen. In a patient experiencing respiratory distress, the primary concern is ensuring an adequate oxygen supply to the body. By administering oxygen, you can help improve oxygenation, which is crucial for the patient's overall well-being. Assessing airway patency is important but administering oxygen takes precedence as it directly addresses the oxygenation concern. Monitoring oxygen saturation is also essential, but the immediate action should be to provide oxygen. Calling for assistance can be important but is not the first priority when dealing with a patient in respiratory distress.

2. A nurse is caring for a client who delivered a full-term newborn 16 hours ago. The nurse notes excessive lochia discharge. Which of the following actions should the nurse take first?

• A. Administer pain medication
• B. Perform a fundal massage
• C. Check the baby's heart rate
• D. Apply an ice pack

Correct answer: B

Rationale: Performing a fundal massage is the priority action in a postpartum client experiencing excessive lochia discharge. Fundal massage helps prevent postpartum hemorrhage by ensuring the uterus contracts effectively. Administering pain medication, checking the baby's heart rate, and applying an ice pack are not the initial interventions needed to address excessive lochia discharge.

3. A nurse is reviewing the plan of care for a client who is taking digoxin. Which of the following findings should the nurse monitor as an adverse effect of this medication?

• A. Hypokalemia
• B. Hypernatremia
• C. Hypertension
• D. Tachycardia

Correct answer: A

Rationale: The correct answer is A: Hypokalemia. Hypokalemia is an adverse effect of digoxin. Digoxin can cause hypokalemia, which increases the risk of toxicity. Monitoring potassium levels is crucial when a client is taking digoxin. Choices B, C, and D are incorrect as hypernatremia, hypertension, and tachycardia are not directly associated with digoxin use.

4. A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP?

• A. The roommate is up independently
• B. The client ambulates with his slippers on over his antiembolic stockings
• C. The client uses a front-wheeled walker when ambulating
• D. The client had pain meds 30 minutes ago

Correct answer: C

Rationale: The correct answer is C. After knee arthroplasty, it is essential for the client to use a front-wheeled walker when ambulating to ensure stability and prevent falls. Sharing this information with the assistive personnel (AP) is crucial for the client's safety and proper rehabilitation. Choices A, B, and D are incorrect because the roommate's independence, the client's footwear over stockings, and the timing of pain medication administration are not directly related to the safe ambulation of a client post-knee arthroplasty.

5. After abdominal surgery, a client has a nasogastric tube attached to low suctioning. The client becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions. Which of the following nursing interventions would be MOST appropriate?

• A. Irrigate the nasogastric tube with distilled water
• B. Aspirate the gastric contents with a syringe
• C. Administer an antiemetic medication
• D. Insert a new nasogastric tube

Correct answer: B

Rationale: The most appropriate nursing intervention when a client with a nasogastric tube experiences nausea and a decrease in gastric secretions is to aspirate the gastric contents with a syringe. This action helps relieve nausea by removing excess fluid and gas. Option A, irrigating the nasogastric tube with distilled water, is not indicated as it does not address the underlying issue of decreased gastric secretions. Option C, administering an antiemetic medication, may provide symptomatic relief but does not address the mechanical issue of decreased flow in the nasogastric tube. Option D, inserting a new nasogastric tube, is not necessary unless there are specific complications or obstructions in the current tube.

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