Nursing Elites

1. What is the first step in managing a patient with a suspected pneumothorax?

• A. Insert a chest tube
• B. Monitor respiratory status
• C. Administer oxygen
• D. Call for assistance

Correct answer: A

Rationale: The correct answer is to insert a chest tube. In managing a patient with a suspected pneumothorax, the priority is to relieve the pressure from the pneumothorax by inserting a chest tube. Monitoring respiratory status (choice B) is important but comes after ensuring proper management of the pneumothorax. Administering oxygen (choice C) can help support oxygenation but does not address the underlying issue of pressure in the thoracic cavity. Calling for assistance (choice D) can be done concurrently with managing the pneumothorax, but the immediate intervention to address the pneumothorax itself is chest tube insertion.

2. What action should the nurse take for a client struggling to void after having an indwelling catheter removed?

• A. Assess for bladder distention after 2 hours
• B. Encourage the client to try urinating in a sitting position
• C. Pour warm water over the client's perineum
• D. Restrict the client's fluid intake

Correct answer: C

Rationale: The correct action for the nurse to take is to pour warm water over the client's perineum. This intervention helps stimulate urination after catheter removal by providing warmth and promoting relaxation of the muscles. Assessing for bladder distention after 2 hours (Choice A) is not the initial intervention to facilitate voiding. Encouraging the client to try urinating in a sitting position (Choice B) may be uncomfortable if the client is struggling to void. Restricting the client's fluid intake (Choice D) is not appropriate as it can further exacerbate the issue by concentrating the urine.

3. A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?

• A. Administer the medication into the client's nondominant arm.
• B. Pull the skin laterally before inserting the needle.
• C. Massage the injection site after administration.
• D. Pinch the skin between the thumb and forefinger.

Correct answer: D

Rationale: The correct action the nurse should take when administering enoxaparin subcutaneously is to pinch the skin between the thumb and forefinger. Pinching the skin helps to lift the subcutaneous tissue, reducing the risk of injecting into the muscle. Choices A, B, and C are incorrect. Choice A is not relevant as the injection site for enoxaparin is typically in the abdomen or thigh, not the arm. Choice B is incorrect as pulling the skin laterally is not a recommended technique for subcutaneous injections. Choice C is also incorrect as massaging the injection site after administration can increase the risk of bleeding or bruising.

4. What is the appropriate intervention for fluid overload?

• A. Restrict fluid intake
• B. Administer diuretics
• C. Monitor vital signs
• D. All of the above

Correct answer: D

Rationale: The appropriate intervention for fluid overload involves a combination of measures, including restricting fluid intake to prevent further fluid accumulation, administering diuretics to help the body eliminate excess fluids, and closely monitoring vital signs to assess the patient's response to treatment. Therefore, all of the above options are correct. Restricting fluid intake alone may not be sufficient to address existing fluid overload without additional measures like diuretic therapy. Monitoring vital signs is essential to evaluate the effectiveness of the interventions and the patient's overall condition.

5. A nurse is collecting data from a postpartum client who had a vaginal birth 2 days ago. Which of the following findings is the nurse's priority to report to the provider?

• A. Bright red bleeding
• B. Burning with urination
• C. Headache
• D. Heavy lochia flow

Correct answer: B

Rationale: The correct answer is B: 'Burning with urination.' Burning with urination can indicate a urinary tract infection postpartum, which requires immediate attention to prevent complications. Bright red bleeding and heavy lochia flow are expected findings in the early postpartum period as the uterus continues to contract and expel lochia. A headache alone is not uncommon postpartum and is often attributed to hormonal changes, dehydration, or fatigue, and can be managed with adequate rest, hydration, and pain relief. Therefore, the priority here is to address the potential infection indicated by burning with urination.

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