Nursing Elites

1. A client with a leg fracture reports increased pain and swelling. What should the nurse suspect?

• A. Compartment syndrome
• B. Deep vein thrombosis
• C. Wound infection
• D. All of the above

Correct answer: A

Rationale: Increased pain and swelling in a fracture could indicate compartment syndrome, a serious condition requiring urgent care. Compartment syndrome is characterized by increased pressure within a muscle compartment, leading to compromised blood flow and potential tissue damage. Deep vein thrombosis is less likely in this scenario as the symptoms are more indicative of compartment syndrome. Wound infection would typically present with localized signs of infection at the wound site, such as redness, warmth, and purulent drainage, rather than diffuse pain and swelling.

2. What safety measure should be implemented when administering chemotherapy?

• A. Use protective gloves and gown
• B. Prepare the medication in a designated area
• C. Administer the medication at the appropriate rate
• D. Verify the two client identifiers

Correct answer: A

Rationale: When administering chemotherapy, it is crucial to use protective gloves and a gown to protect against exposure to hazardous drugs that can be harmful through skin contact. Choice B is incorrect because chemotherapy medication should be prepared in a designated area to prevent contamination and ensure accurate preparation. Choice C is incorrect as chemotherapy should be administered at the appropriate rate to ensure patient safety and avoid adverse effects. Choice D is incorrect as verifying client identifiers is important for medication administration in general but not a specific safety measure related to chemotherapy administration.

3. A client's daughter phones the charge nurse to report that the night nurse did not provide good care for her mother. What response should the nurse make?

• A. Explain that all staff are doing their best
• B. Ask for a description of what happened during the night
• C. Tell the daughter to talk to the unit's nurse manager
• D. Reassure the daughter that the mother will get better care

Correct answer: B

Rationale: The correct response for the nurse in this situation is to ask for a description of what happened during the night. This allows the nurse to gather specific information about the care provided and address the complaint appropriately. Choice A is incorrect because dismissing the concern by stating that all staff are doing their best does not address the specific complaint. Choice C is not the best immediate response as the charge nurse should first gather information before escalating the issue to the nurse manager. Choice D is incorrect as it focuses on reassurance without addressing the reported issue.

4. The client with a diagnosis of hypertension is being taught about lifestyle changes. Which recommendation is most important to include?

• A. Increase sodium intake.
• B. Engage in regular physical activity.
• C. Avoid foods high in fat.
• D. Limit fluid intake to 1 liter per day.

Correct answer: B

Rationale: Engaging in regular physical activity is crucial for individuals with hypertension as it helps lower blood pressure and improve cardiovascular health. Physical activity is known to have a significant impact on reducing hypertension and overall cardiovascular risk. Choice A, increasing sodium intake, is incorrect as reducing sodium is typically recommended for hypertension to help lower blood pressure. Choice C, avoiding foods high in fat, is beneficial for overall health but not the most crucial recommendation for hypertension management. Choice D, limiting fluid intake to 1 liter per day, is not a standard recommendation for hypertension unless advised by a healthcare provider for specific cases. Therefore, the most important recommendation for the client with hypertension is to engage in regular physical activity.

5. While caring for a client's postoperative dressing, the nurse observes purulent wound drainage. Previously, the wound was inflamed and tender but without drainage. Which is the most important action for the nurse to take?

• A. Determine if the drainage has an unpleasant odor.
• B. Monitor the client's white blood cell count (WBC).
• C. Request a culture and sensitivity of the wound.
• D. Cleanse the wound with a sterile saline solution.

Correct answer: C

Rationale: Requesting a culture and sensitivity of the wound is the most crucial action in this scenario. This will help identify the specific organism causing the infection and determine its sensitivity to antibiotics, guiding appropriate antibiotic therapy. Option A is less critical as odor alone may not provide enough information about the type of infection. Monitoring the client's white blood cell count (WBC) in option B is important but not as immediate as obtaining a wound culture. Cleansing the wound with a sterile saline solution in option D is necessary but should follow after obtaining the culture results to ensure proper treatment.

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