Nursing Elites

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

• A. Elevate the client's legs while in bed.
• B. Reposition the client every 2 hours.
• C. Maintain bed rest for the first 24 hours postoperatively.
• D. Ambulate the client on the first postoperative day.

Correct answer: D

Rationale: Ambulating the client on the first postoperative day is crucial to prevent complications like deep vein thrombosis and aid in the recovery process. Elevating the legs while in bed can help with circulation but is not as effective in preventing complications related to immobility post-surgery. Repositioning every 2 hours is important for preventing pressure ulcers but does not directly address postoperative care. Maintaining bed rest for the first 24 hours postoperatively can increase the risk of complications associated with immobility, making early ambulation a more appropriate intervention.

2. What is the most important nursing action for a patient post-surgery?

• A. Monitor vital signs
• B. Monitor the surgical site
• C. Check blood pressure
• D. Check oxygen saturation

Correct answer: A

Rationale: The most crucial nursing action for a patient post-surgery is to monitor vital signs. Monitoring vital signs helps in detecting early signs of complications such as hemorrhage, shock, or infection. While monitoring the surgical site is important for assessing wound healing and signs of infection, it is secondary to monitoring vital signs. Checking blood pressure and oxygen saturation are also important, but they are components of monitoring vital signs.

3. What is the first intervention for a patient experiencing anaphylactic shock?

• A. Administer epinephrine
• B. Administer oxygen
• C. Administer corticosteroids
• D. Administer antihistamines

Correct answer: A

Rationale: The correct answer is to administer epinephrine. Epinephrine is the first-line treatment for anaphylactic shock as it helps reverse the severe allergic reaction by constricting blood vessels, increasing heart rate, and opening airways for improved breathing. Oxygen (Choice B) can be administered after epinephrine to support oxygenation. Corticosteroids (Choice C) may be used to prevent a biphasic reaction but are not the initial intervention. Antihistamines (Choice D) can help with itching and hives but do not address the life-threatening symptoms of anaphylaxis.

4. A healthcare professional is reviewing the laboratory findings of a client who has diabetes mellitus. Which of the following findings indicates a need to revise the client's plan of care?

• A. Serum sodium 144 mEq/L.
• B. HbA1c 10%.
• C. Random serum glucose 190 mg/dL.
• D. Creatinine 1.2 mg/dL.

Correct answer: C

Rationale: Elevated random serum glucose levels of 190 mg/dL indicate hyperglycemia and poor blood sugar control, requiring a revised plan of care. HbA1c levels above 7% also indicate long-term poor control of blood sugar. Serum sodium of 144 mEq/L and creatinine of 1.2 mg/dL are within normal ranges and do not directly indicate a need for a plan of care revision.

5. What is the best way to manage a patient's pain postoperatively?

• A. Administer analgesics regularly
• B. Administer pain medication PRN
• C. Encourage deep breathing exercises
• D. Provide distraction techniques

Correct answer: A

Rationale: The correct answer is A: Administer analgesics regularly. Postoperative pain management often requires a scheduled, around-the-clock administration of analgesics to maintain a consistent level of pain relief and minimize the risk of breakthrough pain. Choice B, administering pain medication PRN (as needed), may lead to inadequate pain control as the medication is not given preemptively. Choice C, encouraging deep breathing exercises, can be beneficial for pain management but should be used as an adjunct to analgesic therapy. Choice D, providing distraction techniques, may help some patients cope with pain but should not be the primary method of pain management postoperatively.

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