Nursing Elites

1. What is the priority nursing action for a patient with shortness of breath?

• A. Administer oxygen
• B. Reposition the patient
• C. Check oxygen saturation
• D. Elevate the head of the bed

Correct answer: A

Rationale: Administering oxygen is the priority nursing action for a patient experiencing shortness of breath. Oxygen therapy aims to improve oxygenation levels quickly, addressing the underlying cause of the symptom. Repositioning the patient, checking oxygen saturation, and elevating the head of the bed are important interventions but administering oxygen takes precedence in this scenario to ensure adequate oxygen supply to the body.

2. A nurse is assessing a client who is 1 day postoperative following a bowel resection. Which of the following findings should the nurse report to the provider?

• A. Urine output of 40 mL/hr.
• B. Heart rate of 88/min.
• C. Wound drainage of 25 mL in 24 hours.
• D. Abdominal distention and rigidity.

Correct answer: D

Rationale: Abdominal distention and rigidity may indicate a postoperative complication, such as bowel obstruction or peritonitis, and should be reported to the provider. While monitoring urine output, heart rate, and wound drainage are essential postoperative assessments, they are not as concerning as abdominal distention and rigidity, which could signal a more urgent issue requiring immediate attention.

3. Four clients present to the emergency department. The nurse should plan to see which of the following clients first?

• A. A 6-year-old client with a dislocated left shoulder
• B. A 26-year-old client with sickle cell disease and severe joint pain
• C. A 76-year-old client who is confused, febrile, and has foul-smelling urine
• D. A 50-year-old client with slurred speech, disorientation, and headache

Correct answer: D

Rationale: The correct answer is D. A client presenting with symptoms of a stroke, such as slurred speech, disorientation, and headache, requires immediate attention due to the possibility of a neurological emergency. Choices A, B, and C, although concerning, do not present with symptoms as urgent as those of a potential stroke. Dislocated shoulder, sickle cell disease with joint pain, and confusion with febrile illness can be addressed after ensuring the client with stroke-like symptoms receives prompt evaluation and intervention.

4. A client with a new diagnosis of hypertension is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will decrease my potassium intake while taking this medication.
• B. I will need to take medication for the rest of my life.
• C. I will avoid using salt substitutes.
• D. I will avoid drinking grapefruit juice.

Correct answer: C

Rationale: The correct answer is C. Clients with hypertension should avoid salt substitutes because they often contain potassium, which can raise potassium levels. Choice A is incorrect as decreasing potassium intake is not necessary unless advised by a healthcare provider. Choice B is incorrect as not all clients with hypertension need to take medication for life. Choice D is incorrect as grapefruit juice does not significantly impact hypertension management.

5. A healthcare provider is reviewing the medical records of a client with a prescription for combination oral contraceptives. Which of the following conditions is a contraindication?

• A. Hyperthyroidism
• B. Thrombophlebitis
• C. Diverticulosis
• D. Hypocalcemia

Correct answer: B

Rationale: Thrombophlebitis is a contraindication to combination oral contraceptives due to the increased risk of thromboembolic events. Hyperthyroidism, diverticulosis, and hypocalcemia are not contraindications to combination oral contraceptives. Hyperthyroidism may affect thyroid hormone levels but does not directly contraindicate oral contraceptives. Diverticulosis is a condition related to the digestive system and does not impact the use of oral contraceptives. Hypocalcemia, a low calcium level in the blood, is not a contraindication for oral contraceptives.

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