Nursing Elites

1. A patient 3 hours post-op from a hysterectomy is complaining of intense pain at the incision site. When assessing the patient, the nurse notes a BP of 169/93, pulse 145 bpm, and regular. What action should the nurse take?

• A. Reassure the patient that pain is normal following surgery.
• B. Administer prn Nifedipine and assess the client's response.
• C. Administer prn Meperidine HCL and assess the client's response.
• D. Recheck BP and pulse rate every 20 minutes for the next hour.

Correct answer: C

Rationale: The correct action for the nurse to take in this situation is to administer prn Meperidine HCL and assess the client's response. A BP of 169/93 and a pulse of 145 bpm indicate pain-related hypertension and sinus tachycardia, which are physiological responses to pain. Treating the cause of the increased pulse rate requires pain medication. Reassuring the patient about normal post-surgery pain is important, but addressing the physiological responses to pain is a priority. Administering Nifedipine, a calcium channel blocker, is not indicated for pain management but for hypertension. Rechecking the BP and pulse rate without addressing the pain directly does not address the underlying issue causing the elevated vital signs.

2. Which of the following microorganisms is easily transmitted from client to client on the hands of healthcare workers?

• A. mycobacterium tuberculosis
• B. clostridium tetani
• C. staphylococcus aureus
• D. human immunodeficiency virus

Correct answer: C

Rationale: The correct answer is staphylococcus aureus. Staphylococcus aureus microorganisms are ubiquitous and easily transmitted by healthcare workers who fail to conduct routine hand washing between clients. Staphylococcus aureus can reside on the skin and be transferred from one client to another if proper hand hygiene is not practiced. Mycobacterium tuberculosis is mainly transmitted through the airborne route, clostridium tetani is usually acquired through exposure to soil or dirt contaminated with tetanus spores, and human immunodeficiency virus is not easily transmitted through casual contact or on the hands of healthcare workers.

3. What is the best position for a client immediately following a bilateral salpingooophorectomy?

• A. Fowler's
• B. Modified Sims
• C. Side lying
• D. Flat supine

Correct answer: C

Rationale: The best position for a client immediately following a bilateral salpingooophorectomy is side lying. This position promotes comfort with the knees flexed and ensures proper airway management. Fowler's position (Choice A) would not be ideal as it involves sitting at a 90-degree angle, potentially causing discomfort after this procedure. Modified Sims position (Choice B) is typically used for rectal examinations, not for post-surgical management. Flat supine (Choice D) may not be the best choice immediately after surgery as it does not provide the same level of comfort and airway protection as side lying with knees flexed.

4. A nurse at an outpatient clinic is returning phone calls that have been made to the clinic. Which of the following calls should have the highest priority for medical intervention?

• A. A home health patient reports, "I am starting to have a breakdown of my heels."?
• B. A patient that received an upper extremity cast yesterday reports, "I can't feel my fingers in my right hand today."?
• C. A young female reports, 'I think I sprained my ankle about 2 weeks ago.'
• D. A middle-aged patient reports, 'My knee is still hurting from the TKR.'

Correct answer: B

Rationale: The correct answer is the patient who received an upper extremity cast yesterday and reports not being able to feel their fingers in the right hand. This situation indicates a potential neurovascular issue that requires immediate attention to prevent complications. The other options are of lesser priority: A - Breakdown of the heels, while concerning, is not an acute issue that necessitates immediate intervention. C - An ankle sprain that occurred two weeks ago is now subacute and unlikely to be an urgent medical concern. D - Pain in the knee following a total knee replacement (TKR) is common in the early postoperative period and is not unexpected.

5. A client who is newly diagnosed with Parkinson's disease and beginning medication therapy asks the nurse, 'How soon will I see improvement?' The nurse's best response is:

• A. "That varies from client to client."?
• B. "You should discuss that with your physician."?
• C. "You should notice a difference in a few days."?
• D. "It might take several weeks before you notice improvement."?

Correct answer: D

Rationale: In the case of Parkinson's disease, improvement in symptoms may take several weeks of therapy to become noticeable. Therefore, the correct answer is to inform the client that it might take several weeks before they notice improvement. Choice A acknowledges individual variability but does not provide a specific timeframe, making it less reassuring. Choice B suggests deferring the question to the physician, which is not the most supportive response. Choice C is incorrect because improvement in Parkinson's disease symptoms typically does not occur within a few days.

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