Nursing Elites

1. The nurse is evaluating a client who has had a mastectomy and is experiencing pain and swelling in the arm on the affected side. What action should the nurse take?

• A. Assess for signs of lymphedema
• B. Encourage the client to perform arm exercises
• C. Provide pain relief through medication
• D. Recommend wearing a compression sleeve

Correct answer: A

Rationale: Assessing for signs of lymphedema is crucial in this situation as it is a common complication following mastectomy. Lymphedema presents as swelling and pain in the affected arm due to compromised lymphatic drainage. By assessing for lymphedema, the nurse can identify the condition early and implement appropriate interventions such as compression sleeves, manual lymphatic drainage, and exercises. Encouraging arm exercises (Choice B) may exacerbate the symptoms if lymphedema is present. While providing pain relief through medication (Choice C) is important, assessing for the underlying cause of pain and swelling takes precedence. Recommending a compression sleeve (Choice D) may be suitable but should come after a thorough assessment for lymphedema to ensure the most effective management plan.

2. After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wishes to see the body before it is taken to the funeral home. Which interventions should the nurse take to prepare the body before the family enters the room? (Select all that apply)

• A. Take out dentures and place them in a labeled cup
• B. Apply a body shroud
• C. Place a small pillow under the head
• D. Gently close the eyes

Correct answer: A

Rationale: The correct interventions for the nurse to prepare the body before the family enters the room include taking out dentures and placing them in a labeled cup. This is essential to ensure the dignity of the deceased and maintain their appearance. Applying a body shroud is not typically done before the family views the body, as it may be more appropriate during preparation for transportation to the funeral home. Placing a small pillow under the head and gently closing the eyes are actions that can be comforting but are not essential preparations for the family viewing.

3. The nurse is caring for a laboring 22-year-old primigravida following administration of regional anesthesia. In planning care for this client, what nursing intervention has the highest priority?

• A. Raising the side rails and placing the call bell within reach
• B. Teaching the client how to push to decrease the length of the second stage of labor
• C. Timing and recording uterine contractions
• D. Positioning the client for proper distribution of anesthesia

Correct answer: D

Rationale: The highest priority nursing intervention for a laboring client following administration of regional anesthesia is to position the client for proper distribution of anesthesia. Proper positioning ensures effective pain management during labor, optimizing the effects of the regional anesthesia. While raising the side rails and placing the call bell within reach (choice A) is important for safety, teaching the client how to push (choice B) and timing and recording uterine contractions (choice C) are vital aspects of care but are not the highest priority immediately after administering regional anesthesia.

4. A female client tells the clinic nurse that she has doubts about binge eating but cannot make herself vomit after meals. Which action by the nurse provides data to support the suspected diagnosis of bulimia?

• A. Ask the client to complete a food diary for the last 3 days
• B. Review the client’s lab data to determine her TSH, T3, and T4 levels
• C. Interview the client about her use of laxatives and diuretics
• D. Encourage the client to describe her daily exercise regimen

Correct answer: C

Rationale: Inquiring about laxative and diuretic use helps confirm bulimia as these are common behaviors associated with the disorder. Asking the client to complete a food diary (Choice A) may provide information on eating patterns but does not directly support the diagnosis of bulimia. Reviewing lab data (Choice B) for thyroid function is not specific to bulimia. Encouraging the client to describe her exercise regimen (Choice D) may be relevant for overall health assessment but does not specifically address bulimia symptoms.

5. The healthcare provider changes a client’s medication prescription from IV to PO administration and doubles the dose. The nurse notes in the drug guide that the prescribed medication, when given orally, has a high first-pass effect and reduces bioavailability. What action should the nurse implement?

• A. Continue administering the medication via the IV route.
• B. Give half the prescribed oral dose until consulting the provider.
• C. Administer the medication orally as prescribed.
• D. Consult with the pharmacist regarding the prescription change.

Correct answer: D

Rationale: The correct action for the nurse to implement is to consult with the pharmacist regarding the change in prescription. With the high first-pass effect of the medication when given orally, it reduces its bioavailability, meaning a dosage adjustment may be necessary to achieve the desired therapeutic effect. Continuing to administer the medication via the IV route (choice A) is not appropriate as the prescription has been changed to oral administration. Giving half the prescribed oral dose until consulting the provider (choice B) is not recommended without proper guidance, which should come from consulting with the pharmacist. Simply administering the medication orally as prescribed (choice C) without addressing the potential issue of reduced bioavailability may lead to suboptimal treatment outcomes.

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