Nursing Elites

1. While assessing a client four hours post-thoracentesis, the nurse is unable to auscultate breath sounds on the right side of the chest. What action should the nurse take first?

• A. Instruct the client to perform cough and deep breathing exercises
• B. Assess the client’s vital signs and respiratory effort
• C. Administer oxygen via nasal cannula according to the PNR protocol
• D. Document assessment findings in the client’s medical record

Correct answer: B

Rationale: The correct first action for the nurse to take in this situation is to assess the client’s vital signs and respiratory effort. It is crucial to promptly detect any immediate complications or changes in the client's condition. Instructing cough and deep breathing exercises (choice A) can be considered after further assessment. Administering oxygen (choice C) should be based on assessment findings and healthcare provider's orders. While documenting the findings (choice D) is essential, it should not be the first action when a potential issue with breath sounds is detected.

2. An older male resident of a long-term care facility has been scratching his legs for the past 2 days. Which intervention should the nurse implement?

• A. Explain the importance of bathing or showering daily
• B. Encourage fluid intake of at least 2,000 ml daily
• C. Keep the legs covered as much as possible
• D. Apply emollient to the affected area at least twice daily

Correct answer: D

Rationale: The correct intervention for the nurse to implement in this scenario is to apply emollient to the affected area at least twice daily. This is because applying emollients helps address dry skin, which is a common cause of itching in older adults. Explaining the importance of bathing or showering daily (Choice A) may be helpful for general hygiene but may not specifically address the itching. Encouraging fluid intake (Choice B) and keeping the legs covered (Choice C) are not directly related to addressing the itching caused by dry skin.

3. An 18-year-old gravida 1, at 41-weeks gestation, is undergoing an oxytocin (Pitocin) induction and has an epidural catheter in place for pain control. With each of the last three contractions, the nurse notes a late deceleration. The client is repositioned, and oxygen provided, but the late decelerations continue to occur with each contraction. What action should the nurse take first?

• A. Prepare for immediate cesarean birth
• B. Turn off the oxytocin (Pitocin) infusion
• C. Notify the anesthesiologist that the epidural infusion needs to be disconnected
• D. Apply an internal fetal monitoring device and continue to monitor carefully

Correct answer: B

Rationale: In the scenario described, the nurse notes late decelerations during contractions despite repositioning and oxygen administration. Late decelerations are often associated with uteroplacental insufficiency, which can be exacerbated by increased uterine activity stimulated by oxytocin. The initial action to manage late decelerations is to turn off the oxytocin infusion to reduce uterine stimulation. This step aims to improve fetal oxygenation and prevent further stress on the fetus. Immediate cesarean birth may be necessary if the late decelerations persist or worsen despite discontinuing the oxytocin infusion. Notifying the anesthesiologist to disconnect the epidural infusion or applying an internal fetal monitoring device are not the first-line interventions for managing late decelerations.

4. The nurse provides discharge teaching to a client who was recently diagnosed with diabetes mellitus (DM). After receiving the instructions, the client expresses understanding about when, how, and why to take his prescribed medications at home. Which intervention is most important for the nurse to implement?

• A. Review the purpose of medications prescribed for the client to take home with him
• B. Provide the client with a printed list of medications and a schedule for administration
• C. Send a list of medications taken while hospitalized to the client’s healthcare provider
• D. Offer to consult with the pharmacist about resources for reduced-price medications

Correct answer: B

Rationale: Providing the client with a printed list of medications and a schedule for administration is crucial to ensure adherence and understanding of the medication regimen at home. This intervention helps the client follow the prescribed treatment plan accurately. Choice A is not as essential since the client already understands when, how, and why to take the medications. Choice C is not a priority at this point as the client needs information for home medication management. Choice D, while helpful, is not the most important intervention compared to providing a clear list and schedule for medication administration.

5. A client with a BMI of 60.2 kg/m² is admitted to the intensive care unit 3 weeks after gastric bypass with gastric rupture and impending multiple organ dysfunction syndrome (MODS). What should the nurse prepare to implement first?

• A. Mechanical ventilation
• B. Platelet transfusion
• C. Loop diuretic therapy
• D. Cyanocobalamin administration

Correct answer: A

Rationale: In this critical situation with gastric rupture and impending MODS, the priority intervention should be mechanical ventilation. This client is at risk of respiratory compromise due to the severity of the condition. Platelet transfusion (Choice B) is not the priority as there is no indication of significant bleeding. Loop diuretic therapy (Choice C) and cyanocobalamin administration (Choice D) are not the immediate priorities in this scenario and would not address the urgent need for respiratory support.

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