Nursing Elites

1. When administering ceftriaxone sodium intravenously to a client before surgery, which assessment finding requires the most immediate intervention by the nurse?

• A. Headache
• B. Pruritus
• C. Nausea
• D. Stridor

Correct answer: D

Rationale: Stridor is a high-pitched, noisy breathing sound that can indicate a serious condition like airway obstruction or a severe allergic reaction, necessitating immediate intervention to maintain the client's airway and prevent further complications. While headache, pruritus, and nausea are important to assess and manage, they are not as immediately life-threatening as stridor, which requires prompt attention to prevent respiratory compromise.

2. The nurse is caring for a laboring 22-year-old primigravida following administration of regional anesthesia. In planning care for this client, what nursing intervention has the highest priority?

• A. Raising the side rails and placing the call bell within reach
• B. Teaching the client how to push to decrease the length of the second stage of labor
• C. Timing and recording uterine contractions
• D. Positioning the client for proper distribution of anesthesia

Correct answer: D

Rationale: The highest priority nursing intervention for a laboring client following administration of regional anesthesia is to position the client for proper distribution of anesthesia. Proper positioning ensures effective pain management during labor, optimizing the effects of the regional anesthesia. While raising the side rails and placing the call bell within reach (choice A) is important for safety, teaching the client how to push (choice B) and timing and recording uterine contractions (choice C) are vital aspects of care but are not the highest priority immediately after administering regional anesthesia.

3. A client with metastatic breast cancer refuses to participate in a clinical trial and further treatments. Her children ask the nurse to convince their mother to reconsider. How should the nurse respond?

• A. Ask the client if she fully understands the decision she has made with her children present.
• B. Discuss the success of clinical trials and ask the client to consider participating for one month.
• C. Explain to the family that they must accept their mother’s decision.
• D. Explore the client’s decision to refuse treatment and offer support.

Correct answer: D

Rationale: The correct response is to explore the client's decision to refuse treatment and offer support. In this situation, it is crucial for the nurse to respect the client's autonomy and decisions regarding her own health. By exploring the client's reasons for refusal, the nurse can better understand her perspective and provide appropriate support. Option A is incorrect as it focuses on questioning the client in front of her children, potentially pressuring her. Option B is inappropriate as it disregards the client's autonomy and tries to persuade her to participate. Option C is also incorrect as it dismisses the client's decision and fails to address the family's concerns in a supportive manner.

4. Which assessment finding is most indicative of deep vein thrombosis (DVT) in a client’s right leg?

• A. Dorsiflexes the right foot and left foot on command
• B. A 3 by 5 cm ecchymosis area on the right calf
• C. Right calf is 3 cm larger in circumference than the left calf
• D. Bilateral lower extremities have 3+ pitting edema

Correct answer: C

Rationale: The correct answer is C because a significant difference in calf circumference between the legs is a classic sign of DVT. This is due to the obstruction of blood flow in the deep veins of the leg, leading to swelling in the affected limb. Choices A, B, and D are not typical findings of DVT. Choice A describes a neurological response, choice B indicates a bruise on the right calf, and choice D describes pitting edema in both lower extremities, which are not specific signs of DVT.

5. While teaching a young male adult to use an inhaler for his newly diagnosed asthma, the client stares into the distance and appears to be concentrating on something other than the lesson the nurse is presenting. What action should the nurse take?

• A. Remind the client of the importance of using a rescue inhaler for asthma management
• B. Leave the client alone to process his thoughts about the inhaler
• C. Ask the client what he is thinking about at that moment
• D. Pause and inquire if the client has any questions or needs clarification

Correct answer: C

Rationale: In this scenario, the most appropriate action for the nurse to take is to ask the client what he is thinking about at that moment. By doing so, the nurse can understand the client's concerns or distractions, which can then be addressed effectively during the teaching session. Option A is incorrect as it assumes the client is not paying attention due to forgetfulness about the importance of the inhaler, which may not be the case. Option B is incorrect because leaving the client alone without addressing the issue does not facilitate effective learning. Option D, although closer, does not directly address the client's distraction and may not uncover the underlying issue causing the lack of focus.

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