Nursing Elites

1. A client who is to undergo a colonoscopy is being taught by a nurse about the procedure. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will drink liquids right up until the procedure.
• B. I will need to stop eating and drinking at least 24 hours before the procedure.
• C. I will be sedated and will not feel any pain during the procedure.
• D. I will not need to follow any specific dietary restrictions for this procedure.

Correct answer: C

Rationale: Choice C is the correct answer. During a colonoscopy, clients are typically sedated, so they do not feel any pain during the procedure. Choices A, B, and D are incorrect. Clients are usually required to stop eating and drinking at least 24 hours before a colonoscopy, and there are specific dietary restrictions that need to be followed before the procedure to ensure a successful examination.

2. A nurse is teaching a client who has peripheral arterial disease (PAD) about exercise recommendations. Which of the following instructions should the nurse include?

• A. Exercise to the point of pain
• B. Stop exercising if pain occurs
• C. Exercise only once per week
• D. Avoid walking to prevent pain

Correct answer: B

Rationale: The correct instruction the nurse should include is to 'Stop exercising if pain occurs.' In peripheral arterial disease (PAD), it is crucial to avoid exercising to the point of pain as this may worsen the condition and lead to complications. Exercising to the point of pain can result in inadequate blood flow to the extremities, causing further damage. By stopping exercise if pain occurs, the client can prevent exacerbating their condition. Choices A, C, and D are incorrect because exercising to the point of pain, limiting exercise to once per week, and avoiding walking altogether are not recommended strategies for managing PAD and could potentially harm the client.

3. A client who had a vaginal delivery 4 hours ago has a fourth-degree perineal laceration. Which of the following interventions should the nurse recommend?

• A. Encourage ambulation
• B. Apply ice packs
• C. Restrict the client's fluid intake
• D. Administer stool softeners

Correct answer: B

Rationale: Correct Answer: Applying ice packs is the most appropriate intervention for a client with a fourth-degree perineal laceration. Ice packs help reduce swelling and promote comfort, aiding in the healing process. Choice A, encouraging ambulation, may not be suitable immediately after a fourth-degree laceration due to the need for rest and proper wound care. Choice C, restricting fluid intake, is not indicated and can lead to dehydration, which is not beneficial for wound healing. Choice D, administering stool softeners, may be necessary to prevent constipation and straining, but it is not the priority intervention at this time.

4. What are early indicators of dehydration?

• A. Dry mouth
• B. Increased thirst
• C. Decreased urine output
• D. Dizziness

Correct answer: A

Rationale: The correct answer is A, dry mouth, and B, increased thirst are early indicators of dehydration. Dry mouth occurs when the body is dehydrated, and increased thirst is the body's way of trying to increase fluid intake to combat dehydration. Choices C and D, decreased urine output and dizziness, can be signs of severe dehydration but are not typically considered early indicators.

5. What are the key signs of increased intracranial pressure (ICP) that a nurse should monitor for?

• A. Monitor for changes in level of consciousness
• B. Check for pupil dilation
• C. Assess for bradycardia
• D. Monitor for vomiting

Correct answer: A

Rationale: The correct answer is A: 'Monitor for changes in the level of consciousness.' Key signs of increased intracranial pressure (ICP) include changes in the level of consciousness and pupil dilation. Assessing for bradycardia and monitoring for vomiting are not typically considered primary signs of increased ICP. While bradycardia and vomiting can occur with increased ICP, they are not as specific or sensitive as changes in consciousness and pupil dilation.

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