Nursing Elites

1. A client is postoperative following a rhinoplasty, and a nurse is contributing to the plan of care. Which of the following interventions should the nurse recommend?

• A. Administer humidified oxygen
• B. Restrict fluids
• C. Instruct the client to avoid the Valsalva maneuver
• D. Apply heat packs to the nose

Correct answer: C

Rationale: Instructing the client to avoid the Valsalva maneuver is crucial after rhinoplasty to reduce strain and the risk of bleeding. Administering humidified oxygen may not be directly related to postoperative care for rhinoplasty. Restricting fluids is not typically necessary unless specifically indicated by the healthcare provider. Applying heat packs to the nose is contraindicated after rhinoplasty as it can increase the risk of bleeding and should be avoided.

2. A client is given morphine 6 mg IV push for postoperative pain. Following administration of this drug, the nurse observes the following: pulse 68, respirations 8, BP 100/68, client sleeping quietly. Which of the following nursing actions is MOST appropriate?

• A. Allow the client to sleep undisturbed
• B. Administer oxygen via facemask or nasal prongs
• C. Administer naloxone (Narcan)
• D. Place epinephrine 1:1,000 at the bedside

Correct answer: C

Rationale: The correct answer is to administer naloxone (Narcan). The client's vital signs indicate opioid-induced respiratory depression, which is a potential side effect of morphine. Naloxone is used to reverse the effects of opioids, particularly to restore normal respiratory function. Administering oxygen alone (Choice B) may not address the underlying cause of respiratory depression. Allowing the client to sleep undisturbed (Choice A) is inappropriate when signs of respiratory depression are present. Epinephrine (Choice D) is not indicated in this situation and is not used to reverse opioid effects.

3. Which of the following is an early indicator that suctioning is needed for a client with a tracheostomy?

• A. Bradycardia
• B. Hypotension
• C. Irritability
• D. Confusion

Correct answer: C

Rationale: Irritability is an early indicator that suctioning is needed for a client with a tracheostomy because it can signal discomfort or difficulty breathing due to mucus accumulation, prompting the need for suctioning to clear the airway. Bradycardia (Choice A) and hypotension (Choice B) are not typically early indicators of the need for suctioning in a client with a tracheostomy. Confusion (Choice D) is also not a direct early indicator of the need for suctioning in this context.

4. A nurse is caring for a client who is experiencing chronic pain. Which of the following interventions should the nurse implement?

• A. Provide the client with distractions such as television
• B. Administer pain medication around the clock
• C. Teach the client relaxation techniques
• D. Perform massage therapy on the client

Correct answer: C

Rationale: The correct intervention for a client experiencing chronic pain is to teach relaxation techniques, as it helps in managing pain more effectively by reducing stress and anxiety. Distractions like television (Choice A) may offer temporary relief but do not address the root cause of chronic pain. Administering pain medication around the clock (Choice B) may lead to dependency and not promote long-term pain management. While massage therapy (Choice D) can be beneficial, teaching relaxation techniques (Choice C) is more directly focused on empowering the client to manage their pain independently.

5. 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.

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