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 has a new diagnosis of heart failure. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 90/min
• B. Serum potassium level of 4.0 mEq/L
• C. Weight gain of 2 kg (4.4 lb) in 2 days
• D. Heart rate of 76/min

Correct answer: C

Rationale: A weight gain of 2 kg (4.4 lb) in 2 days can indicate fluid retention, which is a sign of worsening heart failure and should be reported. This rapid weight gain suggests a fluid overload, putting the client at risk for complications. A heart rate of 90/min is slightly elevated but not as concerning as a sudden significant weight gain. The serum potassium level of 4.0 mEq/L is within the normal range and does not directly indicate worsening heart failure. A heart rate of 76/min is within the normal range and does not raise immediate concerns related to heart failure.

3. A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse take?

• A. Shave hairy areas of skin prior to application.
• B. Wear gloves to apply the patch to the client's skin.
• C. Apply the patch within 1 hr of removing it from the protective pouch.
• D. Remove the previous patch and place it in a tissue.

Correct answer: B

Rationale: The correct answer is to wear gloves to apply the patch to the client's skin. This action ensures that the nurse does not absorb any medication through their own skin, promoting safety. Choice A is incorrect because shaving is not necessary and could irritate the skin. Choice C is incorrect because transdermal patches should be applied immediately after removal from the protective pouch to maintain their efficacy. Choice D is incorrect because used patches should be folded and discarded safely according to facility protocols.

4. 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.

5. A nurse is reviewing the laboratory results of a client who is at 28 weeks of gestation. Which of the following laboratory values should the nurse report to the provider?

• A. Hgb 10 g/dL
• B. Platelets 300,000/mm³
• C. WBC count 12,000/mm³
• D. BUN 18 mg/dL

Correct answer: A

Rationale: The correct answer is A: Hgb 10 g/dL. A hemoglobin level of 10 g/dL is below the normal range for a pregnant client, indicating possible anemia, which is crucial to report during pregnancy to prevent complications for both the mother and the baby. Platelets, WBC count, and BUN levels within the listed values are generally within normal ranges for a pregnant individual at 28 weeks of gestation. Platelets play a role in blood clotting, WBC count helps in fighting infections, and BUN measures kidney function, all of which are typically expected to be within normal limits during pregnancy.

Similar Questions