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. When digitally evacuating stool from a client with a fecal impaction, what action should the nurse take?

• A. Insert a lubricated gloved finger and advance along the rectal wall
• B. Apply lubricant and stimulate peristalsis
• C. Apply pressure to the abdomen to assist with the removal
• D. Increase fluid intake before the procedure

Correct answer: A

Rationale: The correct action when digitally evacuating stool from a client with a fecal impaction is to insert a lubricated gloved finger and advance along the rectal wall. This technique helps prevent trauma and is the appropriate method for addressing fecal impaction. Choice B is incorrect as stimulating peristalsis will not directly assist in evacuating the impacted stool. Choice C is incorrect as applying pressure to the abdomen is not the recommended method for stool evacuation. Choice D is incorrect as increasing fluid intake does not directly aid in digitally evacuating the stool.

3. A nurse is planning care for a client who has chronic obstructive pulmonary disease (COPD). Which of the following interventions should the nurse include?

• A. Encourage the client to take deep breaths.
• B. Administer oxygen as needed.
• C. Teach the client pursed-lip breathing.
• D. Limit the client's fluid intake.

Correct answer: C

Rationale: The correct intervention for a client with COPD is to teach pursed-lip breathing. This technique helps improve oxygenation and reduce dyspnea by promoting better air exchange in the lungs. Encouraging deep breaths may not be suitable for clients with COPD as it can lead to air trapping. Administering oxygen is important in COPD, but teaching pursed-lip breathing is a more direct intervention to help the client manage their condition. Limiting fluid intake is not a standard intervention for COPD and may not be relevant to improving respiratory status.

4. A nurse is assessing a client who is experiencing acute pain. Which of the following manifestations should the nurse expect?

• A. Hypertension
• B. Bradycardia
• C. Diaphoresis
• D. Piloerection

Correct answer: C

Rationale: The correct answer is C: Diaphoresis. Diaphoresis, which is excessive sweating, is a common manifestation of acute pain caused by increased sympathetic nervous system activity. This response is the body's way of trying to regulate body temperature during the stress response. Choices A, B, and D are incorrect. Hypertension (Choice A) and tachycardia (not bradycardia as in Choice B) are more likely responses to acute pain due to sympathetic nervous system activation. Piloerection (Choice D), also known as goosebumps, is not a typical manifestation of acute pain.

5. A nurse is teaching a client who has a new prescription for captopril. Which of the following instructions should the nurse include?

• A. Take this medication with food.
• B. Take this medication 1 hour before meals.
• C. Avoid potassium supplements while taking this medication.
• D. You may experience a persistent, dry cough while taking this medication.

Correct answer: D

Rationale: The correct answer is D. Captopril is known to cause a persistent, dry cough as a common side effect. Instructing the client about this potential side effect is crucial for their awareness. Choices A and B are incorrect because captopril is usually taken on an empty stomach. Choice C is incorrect because captopril can lead to hyperkalemia, so potassium supplements may be necessary in some cases.

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