Nursing Elites

1. A nurse is caring for a client postoperatively. When the nurse prepares to change the dressing, the client says it hurts. Which intervention is the nurse’s priority action?

• A. Administer pain medication 45 minutes prior to dressing change.
• B. Change the dressing quickly to minimize pain.
• C. Provide reassurance to the client that the pain will pass.
• D. Use a less painful dressing technique.

Correct answer: A

Rationale: Administering pain medication before the dressing change is the priority action to help manage the client's pain effectively. This intervention ensures that the client is comfortable during the procedure. Changing the dressing quickly may cause more discomfort to the client. Providing reassurance is important but does not address the immediate pain concern. Using a less painful dressing technique may be helpful, but administering pain medication first is the priority to address the client's pain promptly.

2. A client has been on bed rest for several weeks. Which finding should the nurse identify as the priority during assessment?

• A. Musculoskeletal weakness
• B. Loss of appetite
• C. Increased heart rate during physical activity
• D. Left lower extremity tenderness

Correct answer: D

Rationale: The nurse should prioritize assessing left lower extremity tenderness as it could indicate deep vein thrombosis, a serious condition that requires immediate attention. Musculoskeletal weakness, loss of appetite, and increased heart rate during physical activity are important but not as critical as a potential thrombotic event that could lead to life-threatening complications. Deep vein thrombosis is a common risk for individuals on prolonged bed rest due to reduced mobility and blood stasis.

3. A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management?

• A. ''I think I should take my pain medication more often since it is not controlling my pain.''
• B. ''Breathing faster will help me keep my mind off of the pain.''
• C. ''It might help me to listen to music while I'm lying in bed.''
• D. ''I don't want to walk today because I have some pain.''

Correct answer: C

Rationale: The correct answer is C because listening to music is an effective nonpharmacological intervention for managing mild pain. Choice A is incorrect as increasing the frequency of pain medication without consulting healthcare providers can lead to adverse effects. Choice B is incorrect as distracting techniques like breathing faster may not address the pain effectively. Choice D is incorrect as avoidance of physical activity due to pain can hinder postoperative recovery.

4. The healthcare professional is preparing to administer a tuberculin skin test. Which site is most appropriate for this injection?

• A. Deltoid muscle
• B. Vastus lateralis muscle
• C. Abdomen
• D. Inner forearm

Correct answer: D

Rationale: The inner forearm is the most appropriate site for administering a tuberculin skin test. This test requires an intradermal injection, which is administered just below the surface of the skin. The inner forearm provides a flat, easily accessible surface for this type of injection. Choices A, B, and C are incorrect because the tuberculin skin test should not be administered into a muscle (deltoid muscle or vastus lateralis muscle) or into the abdomen. The test requires precise placement within the dermal layer of the skin on the inner forearm to accurately assess for a reaction.

5. A 2-year-old child is brought to the health care provider's office with a chief complaint of mild diarrhea for 2 days. Nutritional counseling by the nurse should include which statement?

• A. Place the child on clear liquids and gelatin for 24 hours
• B. Continue with the regular diet and include oral rehydration fluids
• C. Give bananas, apples, rice, and toast as tolerated
• D. Place NPO for 24 hours, then rehydrate with milk and water

Correct answer: B

Rationale: In managing mild diarrhea in a 2-year-old child, it is important to maintain their regular diet and include oral rehydration fluids. Choice A of placing the child on clear liquids and gelatin for 24 hours may not provide adequate nutrition and can lead to further electrolyte imbalances. Choice C of giving bananas, apples, rice, and toast as tolerated is a part of the BRAT diet, which is not recommended as the primary approach anymore due to its limited nutritional value. Choice D of placing the child NPO for 24 hours and then rehydrating with milk and water is not appropriate as it can worsen dehydration and delay recovery. Therefore, the best option is to continue the child's regular diet while incorporating oral rehydration fluids to prevent dehydration and maintain nutritional status.

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