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 receiving morphine via a patient-controlled analgesia (PCA) pump. The nurse should identify that which of the following findings is a manifestation of opioid toxicity?

• A. Bradypnea.
• B. Tachycardia.
• C. Hypertension.
• D. Diaphoresis.

Correct answer: A

Rationale: Corrected Rationale: Bradypnea, or slow breathing, is a common sign of opioid toxicity. When a client is experiencing opioid toxicity, the respiratory system is usually the most affected, leading to a decrease in the respiratory rate (bradypnea). Tachycardia (increased heart rate), hypertension (high blood pressure), and diaphoresis (excessive sweating) are not typical manifestations of opioid toxicity. Therefore, the correct answer is bradypnea.

3. A nurse is caring for a client who has severe preeclampsia. Which of the following interventions should the nurse include in the plan of care?

• A. Administer magnesium sulfate.
• B. Place the client in the left lateral position.
• C. Monitor intake and output.
• D. Provide a low-sodium diet.

Correct answer: C

Rationale: The correct intervention for a client with severe preeclampsia is to monitor intake and output. This is crucial to assess kidney function, fluid balance, and detect any signs of deterioration. Administering magnesium sulfate is indicated for seizure prophylaxis in severe preeclampsia, but it is not the primary intervention related to care planning. Placing the client in the left lateral position is not a specific intervention for managing preeclampsia. Providing a low-sodium diet is not typically recommended for clients with severe preeclampsia as sodium restriction is not a primary treatment modality for this condition.

4. What is the most appropriate intervention for a patient with a suspected stroke?

• A. Administer IV fluids
• B. Perform a CT scan
• C. Perform a lumbar puncture
• D. Administer anticoagulants

Correct answer: B

Rationale: The most appropriate intervention for a patient with a suspected stroke is to perform a CT scan. A CT scan is crucial for diagnosing a stroke by visualizing any bleeding or blockages in the brain. Administering IV fluids (Choice A) may be necessary based on the patient's condition, but it is not the primary intervention for a suspected stroke. Performing a lumbar puncture (Choice C) is not indicated for stroke evaluation and may not provide relevant information. Administering anticoagulants (Choice D) is a treatment option for certain types of strokes but should be based on the CT scan results and specific guidelines.

5. What is the most appropriate method to assess a patient's level of consciousness?

• A. Use the Glasgow Coma Scale
• B. Assess the patient's orientation
• C. Check pupillary response
• D. Monitor vital signs

Correct answer: A

Rationale: The correct answer is A: Using the Glasgow Coma Scale. The Glasgow Coma Scale is a standardized tool used to assess a patient's level of consciousness by evaluating their eye response, verbal response, and motor response. This scale provides a numeric value that helps in determining the severity of brain injury or altered mental status. Choices B, C, and D are incorrect because while assessing the patient's orientation, checking pupillary response, and monitoring vital signs are important components of a comprehensive patient assessment, they do not specifically target the assessment of consciousness level, which is best done using the Glasgow Coma Scale.

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