Nursing Elites

1. A client who had an elective below-the-knee amputation reports pain in the foot that was amputated. What is the best response by the nurse?

• A. The pain will go away after the swelling decreases.
• B. That is phantom limb pain.
• C. Your foot has been amputated, so you are not having pain in that foot.
• D. On a scale of 0-10, how would you rate your pain?

Correct answer: D

Rationale: The correct response is to assess the pain intensity by asking the client to rate their pain on a scale of 0-10. This helps the nurse to effectively manage the client's pain. Choice A is incorrect as it dismisses the client's pain without proper assessment. Choice B is incorrect as it assumes the pain is phantom limb pain without assessing the client's current condition. Choice C is incorrect as it invalidates the client's pain experience and does not address the issue at hand.

2. What is the intended outcome for the treatment of glaucoma?

• A. Improve the vision of the eye
• B. Strengthen the muscles of the eye
• C. Lower the intraocular pressure
• D. Dry up excess secretions

Correct answer: C

Rationale: The correct answer is C: Lower the intraocular pressure. The primary objective of treating glaucoma is to reduce intraocular pressure to prevent further vision loss. Choice A, 'Improve the vision of the eye,' is incorrect because while treatment may prevent vision loss, it does not necessarily improve vision. Choice B, 'Strengthen the muscles of the eye,' is incorrect as glaucoma primarily involves the optic nerve and not muscle weakness. Choice D, 'Dry up excess secretions,' is not related to the treatment goal of glaucoma which is focused on managing intraocular pressure.

3. What intervention by the nurse would be the best to prevent deep vein thrombosis after a fracture of the hip?

• A. Encouraging bedrest
• B. Applying antiembolism stockings
• C. Tell the client to take anticoagulants
• D. Teaching about smoking cessation

Correct answer: B

Rationale: The best intervention to prevent deep vein thrombosis (DVT) after a fracture of the hip is to apply antiembolism stockings. These stockings help promote circulation and prevent blood clots from forming in the legs due to immobility. Encouraging bedrest is not recommended as it can increase the risk of DVT. While anticoagulants are used in some cases, the primary prevention method is mechanical prophylaxis like antiembolism stockings. Teaching about smoking cessation is important for overall health but is not directly related to preventing DVT in this scenario.

4. A client has AIDS. Which of these findings indicate possible infection?

• A. Respirations; 22 breaths per minute
• B. Client ambulates 20 feet
• C. Purulent drainage
• D. Oxygen saturation; 97% on room air

Correct answer: C

Rationale:

5. The nurse is planning care for a post-operative client after a total hip arthroplasty. What is the priority nursing intervention?

• A. Observe client for changes in mental status
• B. Use aseptic technique for wound care and emptying of drains
• C. Keep the client's heels off the bed
• D. Perform neurovascular assessments per protocol

Correct answer: D

Rationale:

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