Nursing Elites

1. A client reports severe pain unrelieved by pain medication in a limb with traction. What is the nurse's priority?

• A. Increase the dosage of pain medication.
• B. Assess for compartment syndrome.
• C. Wait for the healthcare provider to address the issue.
• D. Reposition the client to alleviate the pain.

Correct answer: B

Rationale: The correct answer is B: Assess for compartment syndrome. Severe unrelieved pain in a limb with traction can be a sign of compartment syndrome, a surgical emergency. Prompt assessment is crucial to prevent potential complications. Increasing pain medication dosage without addressing the underlying cause may delay necessary interventions. Waiting for the healthcare provider may lead to a critical delay in treatment. Repositioning the client may not alleviate the pain if it is due to compartment syndrome, and it is crucial to assess for this condition first.

2. A nurse is caring for a client and realizes they have administered the wrong medication. Which of the following actions should the nurse take first?

• A. Notify the provider
• B. Check the condition of the client
• C. Document the occurrence in the electronic medical record
• D. Complete an incident report

Correct answer: B

Rationale: The correct answer is to 'Check the condition of the client' first. When a medication error occurs, the nurse's initial priority should be to assess the client's condition to address any immediate harm or side effects. Notifying the provider can come after ensuring the client's safety. Documenting the occurrence in the electronic medical record and completing an incident report are important steps but should follow the assessment of the client's condition to prioritize patient safety.

3. A healthcare provider is providing teaching for a patient with a prescription for oral metronidazole, what is the priority teaching point?

• A. Report headaches
• B. Report a rash
• C. Avoid sunlight
• D. Take with meals

Correct answer: B

Rationale: The correct answer is to 'Report a rash.' Metronidazole can cause severe adverse reactions like Stevens-Johnson syndrome, a life-threatening rash. It is crucial to educate the patient to report any rash immediately to prevent serious complications. Choices A, C, and D are incorrect because while they may be relevant to consider during metronidazole therapy, they are not the priority teaching point. Headaches can occur but are not as serious as a rash; avoiding sunlight is more related to doxycycline, not metronidazole; and taking with meals is a general instruction for some medications but not the priority teaching point for metronidazole.

4. How can dehydration be assessed in an elderly patient?

• A. Checking skin turgor on the forearm
• B. Assessing for dry mucous membranes
• C. Checking for orthostatic hypotension
• D. Measuring daily weights

Correct answer: A

Rationale: Assessing skin turgor by gently pinching the skin on the forearm is a reliable method to check for dehydration in elderly patients. When the skin is slow to return to its original position, it indicates dehydration. While assessing for dry mucous membranes is also important, checking skin turgor is a more direct method for dehydration assessment. Checking for orthostatic hypotension is more related to circulation status than dehydration. Measuring daily weights is helpful to monitor fluid balance but may not be as immediate or direct in detecting dehydration in elderly patients.

5. Which intervention is most effective in preventing deep vein thrombosis (DVT) in a postoperative patient?

• A. Encourage the patient to drink plenty of fluids.
• B. Encourage early ambulation and leg exercises.
• C. Administer anticoagulants as prescribed.
• D. Apply compression stockings to the patient's legs.

Correct answer: B

Rationale: The most effective intervention in preventing deep vein thrombosis (DVT) in a postoperative patient is to encourage early ambulation and leg exercises. Early ambulation helps promote circulation, preventing stasis and reducing the risk of blood clot formation. Encouraging the patient to drink plenty of fluids (choice A) is important for overall health but is not the most effective intervention for preventing DVT. Administering anticoagulants (choice C) is a valuable intervention in some cases, but it may not be suitable for all postoperative patients. Applying compression stockings (choice D) can help prevent DVT but is generally not as effective as early ambulation and leg exercises in postoperative patients.

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