Nursing Elites

1. The nurse is preparing a client for discharge after a major surgical procedure. What is the priority instruction to include in the discharge teaching?

• A. Signs of infection to monitor for
• B. Pain management techniques
• C. Activity restrictions and safety measures
• D. All of the above

Correct answer: D

Rationale: The correct answer is D: All of the above. Providing comprehensive discharge instructions covering signs of infection to monitor for, pain management techniques, activity restrictions, and safety measures is crucial after a major surgical procedure. Each of these components plays a vital role in the client's recovery and well-being. It is important for the client to understand how to identify signs of infection, manage pain effectively, and adhere to activity restrictions to prevent complications and ensure a smooth recovery process. While each instruction is important on its own, combining all aspects into the discharge teaching ensures that the client has a holistic understanding of their post-operative care, empowering them to take charge of their health and know when to seek further assistance if needed. Choices A, B, and C are essential components of discharge teaching and should all be included to provide the client with comprehensive care instructions.

2. The nurse is caring for a client with a diagnosis of major depressive disorder who has been prescribed a selective serotonin reuptake inhibitor (SSRI). What is the most important teaching point?

• A. Take the medication with food.
• B. Expect to see improvement within 24 hours.
• C. Avoid drinking grapefruit juice.
• D. Report any thoughts of self-harm immediately.

Correct answer: D

Rationale: The correct answer is D: 'Report any thoughts of self-harm immediately.' Clients prescribed SSRIs should be educated to report any thoughts of self-harm promptly, as these medications can initially increase suicidal ideation. Choice A is incorrect because SSRIs are usually taken on an empty stomach. Choice B is incorrect as it takes several weeks for SSRIs to reach their full effectiveness. Choice C is irrelevant to SSRI therapy.

3. A hospitalized toddler who is recovering from a sickle cell crisis holds a toy and says, 'Mine.' According to Erikson's theory of psychosocial development, this child's behavior is a demonstration of which developmental stage?

• A. Autonomy vs. Shame and Doubt
• B. Industry vs. Inferiority
• C. Initiative vs. Guilt
• D. Trust vs. Mistrust

Correct answer: A

Rationale: The toddler's behavior of asserting possession ('Mine') reflects a desire for independence, aligning with Erikson's stage of Autonomy vs. Shame and Doubt. This stage, typical for toddlers aged 1-3 years, focuses on developing a sense of control and independence. Choices B, C, and D are incorrect: Industry vs. Inferiority relates to middle childhood, Initiative vs. Guilt pertains to preschoolers, and Trust vs. Mistrust is associated with infancy.

4. When preparing to administer blood to a client, what is the most important action to ensure client safety during this procedure?

• A. Check the client’s blood type compatibility
• B. Monitor the client for signs of transfusion reaction
• C. Verify the correct client and blood product with another healthcare professional
• D. All of the above

Correct answer: D

Rationale: The most important action to ensure client safety during a blood transfusion is to implement multiple safety checks. Checking the client’s blood type compatibility is crucial as it helps prevent major transfusion reactions. Monitoring the client for signs of transfusion reaction is essential to detect any adverse reactions early. Verifying the correct client and blood product with another healthcare professional adds an extra layer of safety by ensuring the right blood is administered to the right patient. Choosing 'All of the above' (Option D) is the correct answer because each action plays a vital role in ensuring the safety and well-being of the client during a blood transfusion. Options A, B, and C are not exclusive; they complement each other to provide comprehensive safety measures.

5. The healthcare provider is preparing to administer a 1.2mL injection to a 4-year-old. Which is the best site to administer an IM injection?

• A. Vastus Lateralis
• B. Radial artery
• C. Dorsogluteal
• D. Rectus femoris

Correct answer: A

Rationale: The correct answer is A, Vastus Lateralis. The vastus lateralis site is recommended for IM injections in small children due to its large muscle mass, making it suitable for injections in pediatric patients. Choices B, C, and D are incorrect. The radial artery is not a site for IM injections; it is a site for arterial puncture. The dorsogluteal site is not recommended for children due to potential risks, such as injury to the sciatic nerve. The rectus femoris is not typically used for IM injections in children, as other sites like the vastus lateralis are more commonly preferred.

Similar Questions