Nursing Elites

1. A nurse is providing discharge teaching to a client who is postoperative following a mastectomy. Which of the following instructions should the nurse include?

• A. Avoid using deodorant until the incision heals.
• B. Perform arm exercises 24 hours after surgery.
• C. Wear tight-fitting clothing to support the incision.
• D. Perform arm exercises 2 days after surgery.

Correct answer: A

Rationale: The correct instruction for the nurse to include is to advise the client to avoid using deodorant until the incision heals. Using deodorant can lead to skin irritation, which should be prevented following a mastectomy. Choice B is incorrect because performing arm exercises should typically be delayed until recommended by the healthcare provider to prevent strain on the surgical site. Choice C is incorrect as tight-fitting clothing can increase discomfort and hinder proper healing. Choice D is also incorrect because initiating arm exercises should be based on the healthcare provider's guidance and not a specific timeframe.

2. A nurse is assessing a client who is postoperative following a hip arthroplasty. Which of the following findings is the priority for the nurse to report?

• A. Heart rate of 90/min
• B. Blood pressure of 118/76 mm Hg
• C. Warmth and redness in the calf
• D. Pink-tinged urine

Correct answer: C

Rationale: The correct answer is C, warmth and redness in the calf. These symptoms may indicate a deep vein thrombosis (DVT), a serious complication following hip arthroplasty that requires immediate attention. A heart rate of 90/min and blood pressure of 118/76 mm Hg are within normal ranges for a postoperative client and do not indicate an urgent issue. Pink-tinged urine may suggest blood in the urine, which should be monitored but is not as critical as the potential DVT.

3. A nurse is caring for a client who is in the orientation phase of the therapeutic relationship. Which statement should the nurse make during this phase?

• A. Let's talk about how you can change your response to stress.
• B. We should establish our roles in the initial session.
• C. Let me show you simple relaxation exercises to manage stress.
• D. We should discuss resources to implement in your daily life.

Correct answer: B

Rationale: During the orientation phase of the therapeutic relationship, it is crucial to establish roles. This helps both the client and the nurse understand their responsibilities, boundaries, and expectations within the therapeutic process. Choice A is more focused on the working phase where strategies and interventions are discussed. Choice C is more suitable for the working phase where specific techniques are usually introduced. Choice D is also more relevant to the working phase as it involves discussing practical resources for implementation in daily life.

4. A client is starting therapy with a statin medication. Which of the following instructions should the nurse include?

• A. Take the medication on an empty stomach.
• B. Avoid consuming grapefruit juice.
• C. Increase intake of dietary fiber.
• D. Take the medication in the morning.

Correct answer: B

Rationale: The correct instruction the nurse should include is to advise the client to avoid consuming grapefruit juice when taking statin medication. Grapefruit juice can interfere with the metabolism of statins, leading to an increased risk of adverse effects. Taking the medication on an empty stomach (Choice A) or in the morning (Choice D) is not specifically necessary for statins. While increasing dietary fiber intake (Choice C) is generally beneficial for health, it is not a specific instruction related to taking statin medication.

5. A nurse is assessing a client who has heart failure and is receiving furosemide. Which of the following findings should the nurse identify as an indication that the client is developing hypokalemia?

• A. Positive Trousseau's sign.
• B. Hyperactive reflexes.
• C. Hypoactive bowel sounds.
• D. Decreased deep-tendon reflexes.

Correct answer: A

Rationale: The correct answer is A: Positive Trousseau's sign. When a patient receiving furosemide is developing hypokalemia, they may exhibit a positive Trousseau's sign, an indication of low potassium levels. This sign is elicited by inflating a blood pressure cuff above systolic pressure for a few minutes, resulting in carpal spasm. Choices B, C, and D are incorrect. Hyperactive reflexes are associated with hyperkalemia, not hypokalemia. Hypoactive bowel sounds are not specifically related to hypokalemia. Decreased deep-tendon reflexes are not typically seen in hypokalemia.

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