Nursing Elites

1. A nurse is planning to teach a group of clients about preventing low back pain. Which of the following information should the nurse include?

• A. Wear low-heeled shoes.
• B. Elevate the legs while sitting.
• C. Engage in prolonged sitting to rest the back muscles.
• D. Sleep on a soft mattress to prevent strain on the back.

Correct answer: A

Rationale: The correct answer is A: 'Wear low-heeled shoes.' Wearing low-heeled shoes helps prevent back strain by promoting proper posture. High heels can cause an imbalance in the body's alignment, leading to increased stress on the lower back. Choices B, C, and D are incorrect. Elevating the legs while sitting can help with circulation but does not directly prevent low back pain. Engaging in prolonged sitting can actually contribute to low back pain due to decreased muscle activity and increased pressure on the spine. Sleeping on a soft mattress may not provide adequate support for the back, potentially worsening back pain instead of preventing it.

2. A nurse is providing teaching about immunizations to a client who is pregnant. The nurse should inform the client that she can receive which of the following immunizations during pregnancy?

• A. Varicella vaccine.
• B. Inactivated polio vaccine.
• C. Tetanus diphtheria and acellular pertussis vaccine.
• D. Inactivated influenza vaccine.

Correct answer: C

Rationale: The correct answer is C: Tetanus diphtheria and acellular pertussis (Tdap) vaccine. The Tdap vaccine can be safely administered during pregnancy to protect both the mother and the newborn against whooping cough. Choices A, B, and D are incorrect because the Varicella vaccine, Inactivated polio vaccine, and Inactivated influenza vaccine are generally not recommended during pregnancy due to safety concerns.

3. A client is 24 hours postoperative following a right-sided mastectomy. Which of the following interventions should the nurse include in the plan of care?

• A. Place the client in the supine position.
• B. Encourage the client to lift objects with the right arm.
• C. Measure the client's blood pressure on the right arm.
• D. Elevate the client's right arm on a pillow.

Correct answer: D

Rationale: Elevating the client's right arm on a pillow is essential post-mastectomy to reduce swelling and promote circulation. Placing the client in the supine position may not be comfortable or ideal after a mastectomy. Encouraging the client to lift objects with the right arm can strain the surgical site and hinder healing. Measuring the client's blood pressure on the right arm should be avoided to prevent disruption to the area and inaccurate readings.

4. A nurse is planning care for a client who has tuberculosis. Which of the following actions should the nurse take to prevent the transmission of the disease?

• A. Place the client in droplet isolation.
• B. Place the client in airborne isolation.
• C. Wear a surgical mask when providing care to the client.
• D. Keep the client's door closed at all times.

Correct answer: B

Rationale: The correct answer is B: 'Place the client in airborne isolation.' Tuberculosis is an airborne disease transmitted through droplet nuclei. Placing the client in airborne isolation helps prevent the spread of the disease to others. Choice A, placing the client in droplet isolation, is incorrect because tuberculosis is not transmitted through large droplets. Choice C, wearing a surgical mask when providing care to the client, is not sufficient as airborne precautions are necessary. Choice D, keeping the client's door closed at all times, does not directly address the prevention of disease transmission in this case.

5. A nurse is caring for a client who is 2 hours postoperative following a thoracotomy. Which of the following findings should the nurse report to the provider?

• A. Chest tube drainage of 60 mL/hr
• B. Oxygen saturation of 95%
• C. Chest tube drainage of 120 mL/hr
• D. Heart rate of 88/min

Correct answer: C

Rationale: The correct answer is C. Chest tube drainage of more than 100 mL/hr may indicate active bleeding, which is a serious complication post-thoracotomy surgery. This finding should be reported to the healthcare provider immediately for further evaluation and intervention. Choices A, B, and D are within normal limits for a client 2 hours post-thoracotomy and do not require immediate reporting. Oxygen saturation of 95% is acceptable, and a heart rate of 88/min is within the normal range for an adult.

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