Nursing Elites

1. A nurse is assessing a client who is 30 minutes postoperative following an arterial thrombectomy. What should the nurse report?

• A. Chest pain.
• B. Muscle spasms.
• C. Cool, moist skin.
• D. Incisional pain.

Correct answer: A

Rationale: In this scenario, postoperative chest pain is a critical finding that must be reported promptly. Chest pain after an arterial thrombectomy could indicate serious complications such as myocardial infarction or pulmonary embolism. Muscle spasms and cool, moist skin are not the priority assessments in this situation. Incisional pain is common after surgery and is not typically a cause for immediate concern unless it is severe and accompanied by other symptoms.

2. While caring for a client receiving total parenteral nutrition (TPN), which of the following actions should the nurse take?

• A. Monitor the client's urine output every 8 hours.
• B. Administer a bolus of 0.9% sodium chloride.
• C. Check the client's blood glucose level every 4 hours.
• D. Flush the TPN line with sterile water before and after administration.

Correct answer: C

Rationale: Checking the client's blood glucose level every 4 hours is essential when managing a client on TPN to monitor for hyperglycemia, a common complication. Monitoring urine output (Choice A) is important but not a priority in this scenario. Administering a bolus of 0.9% sodium chloride (Choice B) is not indicated as it is unrelated to managing TPN. Flushing the TPN line with sterile water (Choice D) is necessary, but it should be done with 0.9% sodium chloride, not water.

3. A nurse is preparing to perform a bladder scan for a client who has overflow incontinence. Which of the following actions should the nurse take?

• A. Place the client in a supine position.
• B. Obtain a prescription for insertion of an indwelling catheter.
• C. Cleanse the client's abdomen with an antiseptic solution.
• D. Prepare the client for urinary catheterization.

Correct answer: D

Rationale: The correct answer is to prepare the client for urinary catheterization. Overflow incontinence may indicate bladder distention, where a bladder scan helps assess the need for catheterization. Placing the client in a supine position (Choice A) is not directly related to the procedure. Obtaining a prescription for an indwelling catheter (Choice B) is not necessary before performing a bladder scan. Cleansing the client's abdomen with an antiseptic solution (Choice C) is not specific to preparing for a bladder scan in this situation.

4. A nurse is planning assignments for a licensed practical nurse (LPN) during a staffing shortage. Which client should be delegated to the LPN?

• A. A client with an Hgb of 6.3 g/dl and a prescription for packed RBCs.
• B. A client who sustained a concussion and has unequal pupils.
• C. A client who is postoperative following a bowel resection with an NG tube set to continuous suction.
• D. A client who fractured his femur yesterday and is experiencing shortness of breath.

Correct answer: C

Rationale: The correct answer is C because the client postoperative following a bowel resection with an NG tube set to continuous suction requires routine postoperative care, which an LPN can manage. Choice A involves administering blood products, which typically requires assessment and monitoring by a registered nurse. Choice B indicates a potentially serious neurological condition that requires assessment by a higher-level provider. Choice D suggests a client experiencing respiratory distress, which requires immediate assessment and intervention by a registered nurse or physician.

5. A client with type 1 diabetes mellitus is being taught self-administration of insulin by a nurse. Which of the following instructions should the nurse include?

• A. Inject air into the vial before withdrawing the insulin.
• B. Draw up the short-acting insulin first, then the long-acting insulin.
• C. Store unopened insulin vials in the freezer.
• D. Rotate injection sites within the same anatomical region.

Correct answer: D

Rationale: The correct instruction the nurse should include is to rotate injection sites within the same anatomical region. This practice helps reduce the risk of lipodystrophy, a condition characterized by fatty tissue changes due to repeated insulin injections in the same spot. By rotating sites, the client ensures better insulin absorption and prevents localized skin changes. Injecting air into the vial before withdrawing insulin (Choice A) is unnecessary and not recommended. Drawing up short-acting insulin before long-acting insulin (Choice B) is not a standard practice and can lead to errors in dosing. Storing unopened insulin vials in the freezer (Choice C) is incorrect as insulin should be stored in the refrigerator, not the freezer, to maintain its effectiveness.

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