Nursing Elites

1. What is the priority nursing action for a patient with respiratory distress?

• A. Administer oxygen
• B. Reposition the patient
• C. Administer bronchodilators
• D. Provide chest physiotherapy

Correct answer: A

Rationale: The priority nursing action for a patient with respiratory distress is to administer oxygen. Oxygen therapy is crucial in improving oxygenation levels and relieving respiratory distress, making it the top priority intervention. Repositioning the patient, administering bronchodilators, or providing chest physiotherapy may be necessary interventions depending on the underlying cause, but ensuring adequate oxygen supply should take precedence in addressing respiratory distress.

2. A nurse is caring for a client who is postoperative following an abdominal surgery. Which of the following assessments should the nurse prioritize?

• A. Assess the client's pain level.
• B. Monitor the client's respiratory rate.
• C. Measure the client's blood pressure.
• D. Check the client's bowel sounds.

Correct answer: B

Rationale: The correct answer is to monitor the client's respiratory rate. This assessment is crucial in the postoperative period to detect any respiratory complications such as hypoxia or respiratory distress. Assessing pain level (Choice A) is important but may not be the top priority as respiratory status takes precedence. Measuring blood pressure (Choice C) is also important but not as critical immediately postoperatively as monitoring respiratory function. Checking bowel sounds (Choice D) is relevant for assessing gastrointestinal function but is typically not the top priority in the immediate postoperative phase.

3. A nurse is caring for a client who has chronic pancreatitis. Which of the following dietary recommendations should the nurse make?

• A. Coffee with creamer
• B. Lettuce with sliced avocados
• C. Broiled skinless chicken breast with brown rice
• D. Warm toast with margarine

Correct answer: C

Rationale: The correct answer is C: Broiled skinless chicken breast with brown rice. This option is suitable for a client with chronic pancreatitis as it is a low-fat, high-protein meal. Clients with pancreatitis should avoid high-fat foods like creamer, margarine, and avocados, making options A, B, and D incorrect choices.

4. A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 ml/hr. What intervention should the nurse anticipate?

• A. Clamp the catheter.
• B. Administer a fluid bolus.
• C. Obtain a urine specimen for culture and sensitivity.
• D. Initiate continuous bladder irrigation.

Correct answer: D

Rationale: In this scenario, the nurse should anticipate initiating continuous bladder irrigation. Dark yellow urine output at a rate of 25 ml/hr following abdominal surgery may indicate urinary stasis or obstruction, which could lead to complications like urinary retention. Continuous bladder irrigation helps prevent catheter obstruction and manage urinary retention by ensuring patency and promoting urine flow. Clamping the catheter (Choice A) could lead to urinary stasis and should be avoided. Administering a fluid bolus (Choice B) is not indicated solely based on the urine color and output described. Obtaining a urine specimen for culture and sensitivity (Choice C) may be necessary for assessing infection but does not directly address the issue of urinary stasis or obstruction.

5. A client is receiving morphine for pain management. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 88/min
• B. Pain rating of 4 on a scale of 0 to 10
• C. Respiratory rate of 10/min
• D. Temperature of 37.2°C (99°F)

Correct answer: C

Rationale: A respiratory rate of 10/min indicates respiratory depression, a serious adverse effect of morphine that should be reported immediately. While a heart rate of 88/min, pain rating of 4, and a temperature of 37.2°C (99°F) are within normal ranges and do not indicate immediate concern related to morphine administration.

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