Nursing Elites

1. What is the most important nursing action when a patient experiences a fall?

• A. Assess the patient for injuries
• B. Call for help
• C. Document the fall
• D. Notify the healthcare provider

Correct answer: A

Rationale: The most important nursing action when a patient experiences a fall is to assess the patient for injuries. This is critical to identify any potential harm or underlying issues that may require immediate attention. Calling for help and notifying the healthcare provider are important steps, but assessing the patient's condition takes precedence to ensure prompt and appropriate care. Documenting the fall is also necessary but should follow the initial assessment and care provided to the patient.

2. A client has a chest tube. Which of the following interventions should the nurse include?

• A. Clamp the chest tube for 15 minutes every 2 hours.
• B. Maintain the drainage system below the client's chest.
• C. Strip the chest tube every 2 hours.
• D. Keep the collection device at the level of the client's chest.

Correct answer: B

Rationale: Maintaining the chest tube drainage system below the client's chest level is crucial to ensure proper drainage and prevent complications. Clamping the chest tube can lead to a tension pneumothorax, stripping the chest tube is an outdated practice that can cause damage to the tissues, and keeping the collection device at the level of the client's chest can impede proper drainage and lead to fluid accumulation.

3. A client is 24 hr postoperative following an abdominal aortic aneurysm resection. Which of the following findings is a priority to report?

• A. Serosanguineous drainage on dressing
• B. Abdominal distention
• C. Absent bowel sounds
• D. Urine output of 20 mL/hr

Correct answer: D

Rationale: Urine output less than 30 mL/hr is indicative of decreased kidney function, potentially due to inadequate perfusion or other complications post-aneurysm resection. This finding requires immediate reporting to prevent further complications such as acute kidney injury. Serosanguineous drainage on the dressing, abdominal distention, and absent bowel sounds are also important postoperative assessments but are not as critical as impaired kidney function in this scenario.

4. When providing teaching for a child prescribed ferrous sulfate, which of the following instructions should the nurse include?

• A. Take with meals
• B. Take at bedtime
• C. Take with a glass of milk
• D. Take with a glass of orange juice

Correct answer: D

Rationale: The correct answer is D, 'Take with a glass of orange juice.' Ferrous sulfate is best absorbed with vitamin C, making orange juice the preferred choice. Choices A, B, and C are incorrect because taking ferrous sulfate with meals, at bedtime, or with milk can reduce its absorption due to interactions with food components like calcium, inhibiting the iron absorption process.

5. A nurse is providing discharge teaching to a client who has a new prescription for nitroglycerin sublingual tablets. Which of the following statements should the nurse include?

• A. Take the medication with food to reduce stomach upset.
• B. Store the medication in a cool, dry place.
• C. Take one tablet every 5 minutes until the pain is relieved, up to three doses.
• D. This medication may cause drowsiness.

Correct answer: C

Rationale: The correct answer is to instruct the client to take one nitroglycerin sublingual tablet every 5 minutes until the pain is relieved, up to three doses. This dosing regimen is essential for managing angina attacks effectively. Choice A is incorrect because nitroglycerin sublingual tablets should be placed under the tongue for rapid absorption, not taken with food. Choice B is incorrect because nitroglycerin tablets should be stored in their original container at room temperature, away from moisture and heat. Choice D is incorrect because nitroglycerin typically does not cause drowsiness as a side effect.

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