Nursing Elites

1. What is the most important assessment for a patient with respiratory distress?

• A. Monitor oxygen saturation
• B. Check for abnormal breath sounds
• C. Check for pitting edema
• D. Perform a neurological exam

Correct answer: A

Rationale: Monitoring oxygen saturation is crucial in assessing a patient with respiratory distress because it helps determine if the patient is receiving adequate oxygen. Oxygen saturation levels provide immediate feedback on the efficiency of oxygen delivery to the tissues. Checking for abnormal breath sounds (Choice B) is relevant in respiratory assessments, but it is secondary to assessing oxygen saturation. Pitting edema (Choice C) and performing a neurological exam (Choice D) are not directly related to assessing respiratory distress and are not the primary focus when managing a patient with breathing difficulties.

2. A client who is postoperative following a colon resection reports pain. Which of the following actions should the nurse take?

• A. Assist the client in changing positions in bed
• B. Administer a PRN dose of morphine
• C. Encourage the client to use relaxation techniques
• D. Offer the client a back massage

Correct answer: B

Rationale: Administering a PRN dose of morphine is the most appropriate action to manage postoperative pain in a client following a colon resection. Morphine is a potent analgesic commonly used to relieve moderate to severe pain, especially in postoperative settings. While assisting the client to change positions in bed, encouraging relaxation techniques, and offering a back massage can provide comfort and support, they may not be sufficient in managing the pain following a major surgical procedure like a colon resection. Therefore, the priority intervention for acute postoperative pain control in this scenario is to administer medication like morphine.

3. What is the most important nursing intervention for a patient experiencing an acute asthma attack?

• A. Administer bronchodilators
• B. Provide supplemental oxygen
• C. Start IV fluids
• D. Monitor oxygen saturation

Correct answer: A

Rationale: The correct answer is to administer bronchodilators. During an acute asthma attack, bronchodilators like albuterol are crucial to help dilate the airways and improve breathing. Providing supplemental oxygen (Choice B) may be necessary but is not the priority intervention. Starting IV fluids (Choice C) and monitoring oxygen saturation (Choice D) are important aspects of care but are not the most critical interventions during an acute asthma attack.

4. A nurse is caring for a client who is postoperative following a total knee arthroplasty. Which of the following interventions should the nurse include in the plan of care?

• A. Apply heat to the incision site.
• B. Keep the client's knee flexed while in bed.
• C. Place a pillow under the client's knee while in bed.
• D. Place a pillow under the client's lower legs.

Correct answer: D

Rationale: Placing a pillow under the client's lower legs is the correct intervention because it helps prevent pressure on the incision site and promotes circulation. Elevating the lower legs also aids in reducing swelling and improving blood flow. Applying heat to the incision site (Choice A) is contraindicated in the early postoperative period as it can increase inflammation and the risk of infection. Keeping the client's knee flexed while in bed (Choice B) may lead to contractures or limited extension of the knee joint. Placing a pillow under the client's knee (Choice C) may cause hyperextension of the knee, which is also not recommended post knee arthroplasty.

5. A nurse is reviewing the medical record of a client who has a history of angina and is scheduled for surgery. Which of the following findings should the nurse report to the provider?

• A. Serum potassium level of 4.2 mEq/L
• B. Blood pressure of 138/84 mm Hg
• C. Platelet count of 150,000/mm³
• D. INR of 2.0

Correct answer: D

Rationale: The correct answer is D. An INR of 2.0 is within the therapeutic range for clients receiving warfarin. It is crucial to report this finding to the provider before surgery to ensure appropriate management and potential adjustments to prevent excessive bleeding risks. Choices A, B, and C are within normal limits and do not directly impact the client's surgery preparation or risk for bleeding, so they do not require immediate reporting.

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