Nursing Elites

1. A client who is to undergo surgery for a hip fracture is being taught by a nurse about postoperative pain management. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will ask for pain medication only if the pain becomes unbearable.
• B. I will ask the nurse to increase my medication if the pain doesn't subside.
• C. I will wait until the pain is severe before taking my medication.
• D. I will take my medication at regular intervals to stay ahead of the pain.

Correct answer: D

Rationale: The correct answer is D because taking pain medication at regular intervals helps maintain consistent pain control after surgery. Option A is incorrect because waiting for the pain to become unbearable can lead to inadequate pain management. Option B is incorrect as it suggests increasing medication without a schedule. Option C is incorrect because waiting for the pain to be severe before taking medication is not proactive pain management.

2. A client with newly diagnosed type I diabetes mellitus is being seen by the home health nurse. The physician orders include: 1,200-calorie ADA diet, 15 units of NPH insulin before breakfast, and check blood sugar qid. When the nurse visits the client at 5 PM, the nurse observes the man performing a blood sugar analysis. The result is 50 mg/dL. The nurse would expect the client to be

• A. Confused with cold, clammy skin and a pulse of 110
• B. Lethargic with hot, dry skin and rapid, deep respirations
• C. Alert and cooperative with a BP of 130/80 and respirations of 12
• D. Short of breath, with distended neck veins and a bounding pulse of 96

Correct answer: A

Rationale: The correct answer is A. Low blood sugar levels (50 mg/dL) typically cause confusion, cold clammy skin, and an increased pulse (tachycardia). Option A correctly describes the expected symptoms of hypoglycemia, which include confusion due to the brain's inadequate glucose supply, cold and clammy skin due to sympathetic nervous system activation, and an increased pulse (110 bpm) as the body reacts to low blood sugar levels. Options B, C, and D describe symptoms that are not typically associated with hypoglycemia. Lethargy, hot dry skin, rapid deep respirations, normal vital signs, shortness of breath, distended neck veins, and bounding pulse are more indicative of other conditions or normal physiological responses, not hypoglycemia.

3. A nurse is preparing to administer an influenza virus immunization to a client by the intradermal route. Which of the following actions should the nurse take?

• A. Avoid massaging the site after injection
• B. Massage the site after injection
• C. Use a circular motion to rub the site
• D. Apply a bandage after injecting

Correct answer: A

Rationale: The correct action for the nurse to take after administering an influenza virus immunization by the intradermal route is to avoid massaging the site. Massaging the site can spread the vaccine, potentially reducing its effectiveness. Rubbing the site in a circular motion or applying a bandage are not recommended actions as they can also interfere with the proper absorption of the vaccine.

4. What are the nursing priorities for a patient experiencing an asthma exacerbation?

• A. Administer a bronchodilator
• B. Encourage deep breathing
• C. Provide oxygen therapy
• D. Monitor oxygen saturation

Correct answer: A

Rationale: The correct nursing priority for a patient experiencing an asthma exacerbation is to administer a bronchodilator. Bronchodilators help in relieving bronchoconstriction and improving breathing. While encouraging deep breathing, providing oxygen therapy, and monitoring oxygen saturation are essential aspects of managing asthma exacerbation, the priority is to administer a bronchodilator to address the acute bronchoconstriction.

5. A client with coronary artery disease (CAD) is being taught about lifestyle changes by a nurse. Which of the following instructions should the nurse include?

• A. Increase your intake of red meat
• B. Increase physical activity to 150 minutes per week
• C. Avoid foods high in fiber
• D. Increase sodium intake to 2,300 mg per day

Correct answer: B

Rationale: The correct answer is B: 'Increase physical activity to 150 minutes per week.' Increasing physical activity is essential for clients with CAD as it helps reduce the risk of cardiovascular events. Choice A is incorrect as red meat is high in saturated fats, which can be detrimental for CAD. Choice C is incorrect as foods high in fiber, such as fruits, vegetables, and whole grains, are beneficial for heart health. Choice D is incorrect as increasing sodium intake can lead to hypertension and worsen CAD.

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