Nursing Elites

1. When preparing the client for a thoracentesis, which action is essential for the nurse to take?

• A. Encourage the client to cough during the procedure
• B. Ask the client to void prior to the procedure
• C. Have the client lie in the prone position
• D. Determine if chest x-rays have been completed

Correct answer: B

Rationale: The essential action for the nurse to take when preparing a client for a thoracentesis is to ask the client to void prior to the procedure. This step is crucial as it helps prevent discomfort and reduces the risk of accidental injury. Encouraging the client to cough during the procedure (Choice A) is inappropriate as it can affect the accuracy of the thoracentesis. Having the client lie in the prone position (Choice C) is incorrect; the procedure is typically performed with the client sitting upright or slightly leaning forward. While determining if chest x-rays have been completed (Choice D) is important, ensuring the client has emptied their bladder is more critical for their comfort and safety during the procedure.

2. Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room?

• A. Ensure that the knot can be quickly released.
• B. Tie the knot with a double turn or square knot.
• C. Move the ties so the restraints are secured to the side rails.
• D. Ensure that the restraints are snug against the client's wrist.

Correct answer: A

Rationale: The correct action for the nurse to take before leaving the room is to ensure that the knot can be quickly released. Using a half bow knot to attach the client's wrist restraints allows for quick release in case of an emergency. This is crucial for ensuring the safety of the client and complying with restraint policies. Tying the knot with a double turn or square knot (Choice B) would make it difficult to release quickly when needed. Moving the ties so the restraints are secured to the side rails (Choice C) does not address the immediate need for a quick release. Ensuring that the restraints are snug against the client's wrist (Choice D) may not be appropriate if the restraints need to be quickly removed for the client's safety.

3. The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply)

• A. Evaluate the client for sleep disturbances
• B. limit client exercise
• C. Report any client complaint of pain or discomfort
• D. Note and report the client's food and liquid intake during meals and snacks

Correct answer: D

Rationale: Weighing the client and monitoring food and liquid intake are appropriate tasks to delegate to the unlicensed assistive personnel (UAP) when managing a client with Cushing's syndrome. These tasks provide essential information for evaluating the client's condition and response to treatment. Evaluating for sleep disturbances and reporting client complaints of pain or discomfort require a higher level of assessment and interpretation, which should be performed by licensed healthcare providers. Therefore, options A and C are tasks that involve assessment and interpretation beyond the scope of practice for UAP.

4. To differentiate adventitious lung sounds associated with heart failure from those associated with bacterial pneumonia, what information should the nurse review?

• A. Sputum culture findings
• B. Oxygen saturation level
• C. Amount of coughing
• D. Respiratory rate

Correct answer: A

Rationale: The correct answer is A: Sputum culture findings. Reviewing sputum culture findings can provide valuable information to differentiate between bacterial pneumonia and heart failure, as the type of bacteria present in the sputum can help identify the specific infection. Oxygen saturation level (Choice B) is important for assessing oxygenation status but does not directly help in distinguishing between the two conditions based on lung sounds. The amount of coughing (Choice C) and respiratory rate (Choice D) may offer some clinical insights but are not as specific or diagnostic as sputum culture findings when differentiating between heart failure and bacterial pneumonia.

5. After successful resuscitation, a client is given propranolol and transferred to the Intensive Coronary Care Unit (ICCU). On admission, magnesium sulfate 4 grams IV in 250 ml D5W at one gram/hour. Which assessment findings require immediate intervention by the nurse?

• A. Dark amber urine draining via an indwelling catheter at a rate of 40 ml per hour
• B. Serum calcium of 9.0 mg/dl (2.2 mmol/L SI) and magnesium of 1.8 mg/dl or Eq/L (0.74 mmol/L SI)
• C. Sinus rhythm at 72 beats/minute and peripheral blood pressure of 99/62
• D. Respiratory rate of 10 breaths per minute

Correct answer: D

Rationale: The correct answer is D. A low respiratory rate of 10 breaths per minute is indicative of possible magnesium toxicity, which can be a serious condition requiring immediate intervention. It is a critical finding that needs prompt attention to prevent further complications. The other options are not as urgent: A - dark amber urine may indicate dehydration but does not require immediate intervention, B - serum calcium and magnesium levels are within normal limits, C - sinus rhythm and blood pressure values are also within normal range and do not require immediate action.

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