Nursing Elites

1. A female client who has been taking oral contraceptives for the past year comes to the clinic for an annual exam. Which finding is most important for the PN to report to the HCP?

• A. Breast tenderness
• B. Change in menstrual flow
• C. Left calf pain
• D. Weight gain of 5 pounds

Correct answer: C

Rationale: Left calf pain could indicate deep vein thrombosis (DVT), a serious side effect of oral contraceptives. Reporting this finding to the healthcare provider is critical for further evaluation and treatment. Breast tenderness and change in menstrual flow are common side effects of oral contraceptives and may not be as urgent as left calf pain. Weight gain of 5 pounds, while noteworthy, is not as concerning as a possible indication of DVT.

2. You have a patient who has just had a diagnostic arthroscopy. You are instructing him about what to do when he gets home. Which of the following would you NOT instruct him to do?

• A. Resume normal activities within 12 hours so as to help reduce the swelling
• B. Elevate the extremity for 24 – 48 hours
• C. Apply ice to the area involved intermittently
• D. Report severe pain to the physician immediately

Correct answer: A

Rationale: Patients should rest and avoid normal activities for a short period after arthroscopy to allow healing and prevent swelling, which could worsen with early activity. Elevation and icing are recommended post-procedure to reduce swelling and pain. Instructing the patient to resume normal activities within 12 hours could lead to increased swelling and delayed healing. Reporting severe pain is crucial as it could indicate a complication. Therefore, the correct instruction is not to resume normal activities immediately after arthroscopy.

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. A new mother who is breastfeeding her newborn for the first time after delivery reports nipple pain when the baby sucks. Based on this client problem, which action should the PN take?

• A. Ensure that all the areolar tissue of the nipple is in the infant's mouth
• B. Have the mother reposition the infant from the cradle to the football hold
• C. Check for engorgement and assess the nipples for cracks or lesions
• D. Apply a warm compress to the breast for 10 minutes before each feeding

Correct answer: A

Rationale: Proper latch, including all the areolar tissue in the infant's mouth, is essential to prevent nipple pain and ensure effective breastfeeding. Option A is correct because ensuring that all the areolar tissue of the nipple is in the infant's mouth helps achieve a good latch, reducing nipple pain. Option B is incorrect as repositioning the infant may not address the root cause of the pain related to latch issues. Option C is incorrect because while checking for engorgement and nipple issues is important, it does not directly address the latch concern causing the pain. Option D is incorrect as applying a warm compress is not recommended for breastfeeding mothers; a warm compress can help with pain associated with engorgement, but it does not address latch issues.

5. Which type of isolation precaution is required for a patient with tuberculosis (TB)?

• A. Droplet precautions
• B. Contact precautions
• C. Airborne precautions
• D. Standard precautions

Correct answer: C

Rationale: The correct answer is C: Airborne precautions. Tuberculosis (TB) is transmitted via airborne particles, thus requiring airborne precautions to prevent the spread of infection. This includes using an N95 respirator to filter out small infectious particles. Droplet precautions (Choice A) are used for diseases that spread through large respiratory droplets. Contact precautions (Choice B) are for direct or indirect contact with the patient or their environment. Standard precautions (Choice D) are used for all patients to prevent the spread of infection through blood, bodily fluids, non-intact skin, and mucous membranes.

Similar Questions