Nursing Elites

1. A client is admitted with acute low back pain. What action should the nurse implement to promote comfort?

• A. Ambulate with a walker for upper body support
• B. Perform abdominal curls to stretch the back muscles
• C. Position in semi-Fowler's with the knees flexed
• D. Encourage straight leg raises while lying supine

Correct answer: C

Rationale: Positioning the client in semi-Fowler's with the knees flexed is the most appropriate action to promote comfort in a client with acute low back pain. This position helps alleviate low back pain by reducing the pressure on the spine and supporting its natural curvature. Ambulating with a walker could strain the back, performing abdominal curls may exacerbate the pain, and straight leg raises while lying supine could cause further discomfort. Therefore, only positioning the client in semi-Fowler's with the knees flexed is the correct choice for promoting comfort in this scenario.

2. When assessing a mildly obese 35-year-old female client, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. What is the most likely explanation for the failure to locate the gallbladder by palpation?

• A. The client is too obese.
• B. Palpating in the wrong location.
• C. The gallbladder is normal.
• D. Deeper palpation technique is needed.

Correct answer: A

Rationale: The correct answer is A. Obesity can make it difficult to palpate the gallbladder due to increased abdominal tissue, making it challenging to locate specific structures. Choice B is incorrect because the nurse is palpating in the correct location below the liver margin at the lateral border of the rectus abdominal muscle, where the gallbladder is typically located. Choice C is incorrect as the inability to palpate the gallbladder does not necessarily indicate abnormality; it may be due to anatomical variations or technical challenges. Choice D is incorrect as the issue lies more with the difficulty posed by excess adipose tissue rather than the need for deeper palpation techniques.

3. A school nurse is called to the soccer field because a child has a nosebleed (epistaxis). In what position should the nurse place the child?

• A. Sitting up and leaning forward
• B. Reclining with head elevated
• C. Sitting up with head tilted back
• D. Lying flat on the back

Correct answer: A

Rationale: The correct position for a child with a nosebleed (epistaxis) is sitting up and leaning forward. This position helps prevent blood from flowing into the throat and causing choking. Choice B, reclining with the head elevated, and choice D, lying flat on the back, are incorrect as they can cause blood to flow backward into the throat. Choice C, sitting up with the head tilted back, is also incorrect as it can lead to blood flowing down the back of the throat and potentially into the airway.

4. The parents of a child who had surgical repair of a myelomeningocele are being taught how to change an occlusive dressing on the child’s back. Which statement by the parents indicates that they understand this procedure?

• A. When changing the dressing, the tape should be removed slowly to prevent trauma to the skin
• B. To prevent infection, the dressing should be kept dry to avoid excess moisture
• C. The skin incision should be kept moist to promote healing and prevent dryness
• D. The incision should be protected from fecal contamination by an intact dressing

Correct answer: D

Rationale: The correct answer is D because protecting the incision from fecal contamination is essential to prevent infection and promote healing in a child with a myelomeningocele. This is crucial as fecal matter can introduce harmful bacteria to the wound. Choice A is incorrect as removing the tape slowly to prevent trauma to the skin is a general guideline but not specific to preventing infection. Choice B is incorrect because keeping the dressing dry can lead to complications as the wound needs a moist environment to heal properly. Choice C is incorrect as keeping the skin incision moist may promote infection and delay healing, making it an incorrect statement for postoperative care.

5. When designing a plan of care for a client diagnosed with pheochromocytoma, a goal statement should be prepared that relates to which topic?

• A. Psychological counseling to address emotional well-being
• B. Medication teaching concerning adrenergic blockers
• C. Preoperative and postoperative teaching for adrenalectomy
• D. Education on dietary modifications for hypertension

Correct answer: C

Rationale: The correct answer is C: Preoperative and postoperative teaching for adrenalectomy. Pheochromocytoma often requires adrenalectomy as part of the treatment plan. Therefore, educating the client about what to expect before and after the surgery is crucial for optimal care and outcomes. Choices A, B, and D are incorrect. Choice A focuses on emotional well-being rather than the specific surgical intervention needed for pheochromocytoma. Choice B is unrelated as the primary treatment for pheochromocytoma is surgical rather than medication-based. Choice D, though related to managing hypertension, does not address the surgical aspect of treating pheochromocytoma.

Similar Questions