Nursing Elites

1. A nurse is caring for a client who has returned to the medical-surgical unit following a transurethral resection of the prostate (TURP). Which of the following should the nurse identify as a priority nursing assessment after reviewing the client's information?

• A. Level of consciousness.
• B. Skin turgor.
• C. Deep-tendon reflexes.
• D. Bowel sounds.

Correct answer: A

Rationale: The correct answer is A: Level of consciousness. Following a TURP procedure, monitoring the client's level of consciousness is crucial as it can indicate potential postoperative complications such as hemorrhage or shock. Skin turgor (choice B) is more related to hydration status, deep-tendon reflexes (choice C) are not the priority post-TURP, and bowel sounds (choice D) are important but not the priority in this situation.

2. A nurse is caring for a client who is in Buck's traction. Which of the following actions should the nurse take?

• A. Remove the weights
• B. Ensure the weights hang freely
• C. Increase the traction force
• D. Loosen the ropes

Correct answer: B

Rationale: The correct action the nurse should take when caring for a client in Buck's traction is to ensure the weights hang freely. This is essential to maintain proper alignment and ensure the effectiveness of Buck's traction. Removing the weights (Choice A) would be incorrect and could compromise the treatment. Increasing the traction force (Choice C) can lead to excessive pressure and potential harm to the client. Loosening the ropes (Choice D) would also be inappropriate as it can disrupt the traction's effectiveness and alignment.

3. What are the early signs of a pulmonary embolism?

• A. Chest pain, shortness of breath, and tachycardia
• B. Fever, nausea, and vomiting
• C. Cough, cyanosis, and fatigue
• D. Abdominal pain and bradycardia

Correct answer: A

Rationale: The correct answer is A: Chest pain, shortness of breath, and tachycardia. These are classic early signs of a pulmonary embolism. Chest pain may be sudden and sharp, worsened by deep breathing or coughing. Shortness of breath can be sudden and severe. Tachycardia (rapid heart rate) is another common symptom. Choices B, C, and D are incorrect as they do not represent typical early signs of a pulmonary embolism.

4. A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk of injury for this client?

• A. Use a bed exit alarm system
• B. Raise all four side rails while the client is in bed
• C. Apply one soft wrist restraint
• D. Dim the lights in the client's room

Correct answer: A

Rationale: Using a bed exit alarm system is crucial in minimizing the risk of injury for a client with dementia. This intervention helps alert staff when the client is attempting to leave the bed, reducing the chances of falls. Raising all four side rails while the client is in bed (Choice B) can lead to restraint-related issues and is not recommended unless necessary for safety reasons. Applying a soft wrist restraint (Choice C) is generally not the first choice in managing clients with dementia due to the risk of complications and loss of mobility. Dimming the lights in the client's room (Choice D) may not directly address the risk of injury associated with dementia and may even increase the risk of falls due to poor visibility.

5. A nurse is reinforcing teaching about ways to reduce solid fat consumption with a client who has an elevated cholesterol level. Which of the following instructions should the nurse include?

• A. Use oils with trans fats
• B. Choose lean cuts of beef
• C. Avoid purchasing beef that is a loin cut
• D. Purchase chicken instead of lamb

Correct answer: B

Rationale: The correct answer is B: 'Choose lean cuts of beef.' Selecting lean cuts of beef is crucial in reducing solid fat consumption for individuals with high cholesterol levels. Lean cuts contain less saturated fat compared to fatty cuts, thus aiding in managing cholesterol levels. Option A is incorrect as oils with trans fats should be avoided since they contribute to unhealthy fats. Option C is not directly related to reducing solid fat consumption. Option D, while suggesting a leaner meat option, does not address the issue of solid fat consumption as directly as choosing lean cuts of beef.

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