Nursing Elites

1. A nurse is planning care for a client who is postoperative following a bowel resection. Which of the following interventions should the nurse include?

• A. Encourage the client to drink adequate fluids daily.
• B. Administer pain medication as needed.
• C. Instruct the client to splint the incision with a pillow.
• D. Encourage the client to eat a balanced diet.

Correct answer: C

Rationale: The correct intervention for a client post-bowel resection is to instruct the client to splint the incision with a pillow. This technique helps prevent dehiscence, which is the separation of wound edges, and reduces pain when coughing or moving. Splinting supports the incision site, decreasing tension on the wound. Encouraging the client to drink adequate fluids promotes hydration and aids in recovery, but a specific volume like 1,000 mL mentioned in choice A is not essential. Pain medication should be administered as needed for adequate pain control, not necessarily before every meal. Instructing the client to eat a balanced diet, including adequate protein, is crucial for wound healing and overall recovery, rather than limiting protein intake.

2. A client with a new diagnosis of Graves' disease and a prescription for propylthiouracil (PTU) is receiving teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?

• A. I should report a sore throat to my provider.
• B. I will need to take this medication for the rest of my life.
• C. This medication increases my risk for infection.
• D. This medication decreases my appetite.

Correct answer: C

Rationale: The correct answer is C because propylthiouracil (PTU) can increase the risk of infection. Therefore, the client should be aware that this medication may compromise their immune system, making them more susceptible to infections. Reporting any signs of infection promptly to the provider is crucial for timely intervention and management. Choices A, B, and D are incorrect because reporting a sore throat, assuming lifelong medication intake, or experiencing decreased appetite are not directly related to the medication's side effects or risks.

3. What is the most appropriate method to assess a patient's level of consciousness?

• A. Use the Glasgow Coma Scale
• B. Assess the patient's orientation
• C. Check pupillary response
• D. Monitor vital signs

Correct answer: A

Rationale: The correct answer is A: Using the Glasgow Coma Scale. The Glasgow Coma Scale is a standardized tool used to assess a patient's level of consciousness by evaluating their eye response, verbal response, and motor response. This scale provides a numeric value that helps in determining the severity of brain injury or altered mental status. Choices B, C, and D are incorrect because while assessing the patient's orientation, checking pupillary response, and monitoring vital signs are important components of a comprehensive patient assessment, they do not specifically target the assessment of consciousness level, which is best done using the Glasgow Coma Scale.

4. A nurse is planning care for a client who is receiving hemodialysis. What action should the nurse include in the plan?

• A. Withhold all medications until after dialysis.
• B. Rehydrate with dextrose 5% in water for orthostatic hypotension.
• C. Check the vascular access site for bleeding after dialysis.
• D. Give an antibiotic 30 minutes before dialysis.

Correct answer: C

Rationale: The correct action that the nurse should include in the plan for a client receiving hemodialysis is to check the vascular access site for bleeding after dialysis. This is important to prevent complications such as infection or excessive bleeding. Withholding all medications until after dialysis (Choice A) is not necessary unless specific medications need to be avoided due to the dialysis process. Rehydrating with dextrose 5% in water for orthostatic hypotension (Choice B) is not directly related to post-dialysis care. Giving an antibiotic 30 minutes before dialysis (Choice D) is not a standard practice unless there is a specific clinical indication.

5. A nurse is caring for a client who is at 32 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?

• A. Blood pressure of 120/80 mm Hg
• B. Respiratory rate of 16/min
• C. 1+ protein in the urine
• D. Heart rate of 88/min

Correct answer: C

Rationale: The correct answer is C. 1+ protein in the urine is indicative of worsening preeclampsia and should be reported to the provider immediately. Elevated blood pressure (choice A) is expected in preeclampsia, but a reading of 120/80 mm Hg is within the normal range. A respiratory rate of 16/min (choice B) and a heart rate of 88/min (choice D) are also within normal limits and not indicative of worsening preeclampsia.

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