Nursing Elites

1. A client who is immobile needs interventions to prevent contractures. Which of the following interventions is appropriate?

• A. Aligning a trochanter wedge between the client's legs.
• B. Placing a towel roll under the client's neck.
• C. Applying an orthotic to the client's foot.
• D. Positioning a pillow under the client's knees.

Correct answer: C

Rationale: Applying an orthotic to the client's foot is the appropriate intervention to prevent contractures in an immobile client. An orthotic helps maintain proper alignment and prevents the development of contractures by keeping the foot in the correct position. Choices A, B, and D are incorrect because a trochanter wedge, towel roll under the neck, and pillow under the knees are not specific interventions for preventing contractures in an immobile client.

2. A nurse is collecting data from a client who delivered a full-term newborn 16 hours ago. The nurse notes excessive lochia discharge. Which of the following actions should the nurse take first?

• A. Administer pain medication
• B. Perform a fundal massage for the client
• C. Check the baby's heart rate
• D. Apply an ice pack

Correct answer: B

Rationale: The correct action the nurse should take first when noting excessive lochia discharge in a client who delivered a full-term newborn 16 hours ago is to perform a fundal massage. Fundal massage helps stimulate uterine contractions, which in turn reduces bleeding in postpartum clients. Administering pain medication (Choice A) is not the priority in this situation as addressing the excessive lochia discharge is crucial to prevent complications. Checking the baby's heart rate (Choice C) is important but not the first action to manage the mother's condition. Applying an ice pack (Choice D) is not appropriate for managing excessive lochia discharge; fundal massage is the initial intervention to address this issue effectively.

3. The nurse is making a home visit with a client diagnosed with Alzheimer's disease. The client recently started on lorazepam (Ativan) due to increased anxiety. The nurse is cautioning the family about the use of lorazepam (Ativan). The nurse should instruct the family to report which of the following significant side effects to the healthcare provider?

• A. Paradoxical excitement
• B. Headache
• C. Slowing of reflexes
• D. Fatigue

Correct answer: A

Rationale: The correct answer is A, paradoxical excitement. Lorazepam can cause an unexpected response of paradoxical excitement, which should be reported to the healthcare provider. This reaction is characterized by increased anxiety, restlessness, and agitation instead of the expected calming effect. Choices B, C, and D are incorrect because headache, slowing of reflexes, and fatigue are more common side effects of lorazepam and may not warrant immediate reporting unless severe or persistent.

4. 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.

5. What are the early signs of diabetic ketoacidosis?

• A. Excessive thirst and fruity breath odor
• B. Weight loss and increased urination
• C. Nausea and vomiting
• D. Hypoglycemia and fatigue

Correct answer: A

Rationale: The correct answer is A: Excessive thirst and fruity breath odor. Diabetic ketoacidosis presents with these early signs due to ketone buildup in the body. Choice B, weight loss and increased urination, are more characteristic of uncontrolled diabetes but not specific to diabetic ketoacidosis. Choice C, nausea and vomiting, can occur in diabetic ketoacidosis but are not as early or specific as excessive thirst and fruity breath odor. Choice D, hypoglycemia and fatigue, are not typical signs of diabetic ketoacidosis; rather, diabetic ketoacidosis usually presents with hyperglycemia.

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