Nursing Elites

1. A client who is post-operative from a spinal fusion surgery reports a sudden onset of severe headache when sitting up. What is the nurse’s priority action?

• A. Administer pain medication.
• B. Lay the client flat and notify the healthcare provider.
• C. Encourage the client to drink more fluids.
• D. Assess the client’s surgical site for drainage.

Correct answer: B

Rationale: In this scenario, the correct action is to lay the client flat and notify the healthcare provider. A severe headache in a post-operative spinal fusion patient can indicate a spinal fluid leak, which is a medical emergency. By laying the client flat, the nurse helps reduce symptoms by decreasing pressure differentials. Administering pain medication without further assessment or intervention is inappropriate before identifying the cause of the headache. Encouraging the client to drink more fluids is not the priority when a serious complication like a spinal fluid leak is suspected. While assessing the surgical site is important, it is not the priority when a potentially life-threatening complication is suspected.

2. Which action should the PN implement when using standard precautions to provide client care?

• A. Apply sterile gloves to obtain a finger stick blood sample
• B. Wear clean exam gloves to perform perineal catheter care
• C. Replace the needle cap after giving an intramuscular injection
• D. Wear a paper gown to prevent transmission of droplet pathogens

Correct answer: B

Rationale: The correct answer is B. When using standard precautions, healthcare providers should wear clean exam gloves to perform perineal catheter care. This approach helps prevent the transmission of pathogens and ensures the safety of both the client and the healthcare provider. Choice A is incorrect because applying sterile gloves for a finger stick blood sample is unnecessary when non-sterile gloves would suffice. Choice C is incorrect because replacing the needle cap after giving an intramuscular injection is not directly related to standard precautions. Choice D is incorrect because wearing a paper gown is not a standard precaution for preventing the transmission of droplet pathogens.

3. A client who had a left hemicolectomy is experiencing a low-grade fever on post-operative day three. What is the nurse's best action?

• A. Encourage deep breathing and the use of the incentive spirometer.
• B. Administer antipyretic medication as prescribed.
• C. Notify the healthcare provider immediately.
• D. Increase the client’s fluid intake.

Correct answer: A

Rationale: A low-grade fever on post-operative day three can be a sign of atelectasis, a common post-operative complication. Encouraging deep breathing and the use of the incentive spirometer can help prevent and treat this condition. Atelectasis is often due to shallow breathing, so option A is the best initial action to promote lung expansion. Administering antipyretic medication (option B) may help reduce the fever but does not directly address the underlying cause. Notifying the healthcare provider immediately (option C) is not necessary at this point unless other concerning symptoms are present. Increasing the client’s fluid intake (option D) is important for overall recovery but is not the priority in this scenario.

4. Which of the following components of nutrition has a primary function of helping with tissue growth and repair?

• A. Vitamin D
• B. Vitamin E
• C. Protein
• D. Fat

Correct answer: C

Rationale: Protein is the correct answer as it is essential for tissue growth and repair. Proteins are composed of amino acids, the building blocks of body tissues. While vitamins D and E have important roles in the body, they are not primarily responsible for tissue growth and repair. Fats are crucial for various bodily functions, like providing energy, but they are not the primary component involved in tissue growth and repair.

5. According to the principle of asepsis, which situation should the PN consider to be sterile?

• A. A one-inch border around the edges of a sterile field set up in the operating room
• B. A sterile glove that the PN thinks might have touched hair
• C. A wrapped, unopened sterile 4x4 gauze pad placed on a damp table top
• D. An open sterile Foley catheter kit set up on a table at the PN's waist level

Correct answer: A

Rationale: According to the principle of asepsis, the one-inch border around the edges of a sterile field set up in the operating room is considered non-sterile, while the central area remains sterile. Therefore, the PN should consider the situation described in choice A to be sterile. Choice B is incorrect because a glove that may have touched hair is contaminated. Choice C is incorrect as a sterile item placed on a damp surface is considered contaminated. Choice D is incorrect as a sterile kit set up at the PN's waist level is prone to contamination.

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