Nursing Elites

1. The client with a below-the-knee amputation is being taught about proper care of the residual limb. The most important point to emphasize would be

• A. Wrap the stump with an elastic bandage to prevent swelling
• B. Keep the skin on the stump clean and dry
• C. Use alcohol to cleanse the stump daily
• D. Apply moisturizing lotion to the stump daily

Correct answer: B

Rationale: The correct answer is B: Keep the skin on the stump clean and dry. This is crucial for preventing infection and promoting healing of the residual limb. Wrapping the stump with an elastic bandage can constrict blood flow and cause issues. Using alcohol to cleanse the stump daily can be too harsh and drying for the skin, leading to irritation. Applying moisturizing lotion daily is not as essential as keeping the skin clean and dry to prevent complications.

2. An 11-year-old client admitted to the mental health unit after threatening self-harm. What is the best activity to establish rapport and promote coping?

• A. Bring the client to the team meeting to discuss the treatment plan.
• B. Play a board game with the client and start discussing stressors.
• C. Explain the purpose of each medication the client is taking.
• D. Ask the client to write feelings in a journal and review together.

Correct answer: B

Rationale: Playing a board game with the client is an effective way to establish rapport in a relaxed setting, allowing the client to open up about stressors. This activity promotes coping by creating a safe and engaging environment for the client to express their feelings. Choices A, C, and D may not be suitable initially as they involve more formal or intrusive approaches that may not be suitable for building rapport with a client experiencing emotional distress.

3. Which intervention should be included in the long-term plan of care for a client with COPD?

• A. Administer high-flow oxygen during sleep.
• B. Reduce risk factors for infection.
• C. Limit fluid intake to reduce secretions.
• D. Use diaphragmatic breathing to achieve better exhalation.

Correct answer: D

Rationale: The correct answer is D: 'Use diaphragmatic breathing to achieve better exhalation.' Diaphragmatic breathing is an essential intervention for clients with COPD as it helps improve exhalation and lung function, ultimately reducing symptoms over the long term. Option A is incorrect because high-flow oxygen during sleep is more relevant for clients with conditions like sleep apnea rather than COPD. Option B, 'Reduce risk factors for infection,' is important but not as specific to the long-term management of COPD as diaphragmatic breathing. Option C, 'Limit fluid intake to reduce secretions,' is not a recommended intervention for clients with COPD, as adequate hydration is crucial for maintaining respiratory health.

4. The healthcare provider prescribes a sedative for a client with severe hypothyroidism. What is the best action for the nurse to take?

• A. Affirm the nurse's plan to review the prescription with the provider.
• B. Administer the sedative as prescribed.
• C. Advise the nurse to administer the medication as prescribed.
• D. Offer to administer the medication since the nurse is concerned.

Correct answer: A

Rationale: The correct answer is to affirm the nurse's plan to review the prescription with the provider. Sedatives can worsen symptoms of hypothyroidism, so it is crucial to ensure the safety of the prescribed medication. Administering the sedative without further consultation could lead to adverse effects. Simply advising the nurse to administer the medication without addressing the need for review is not the best course of action. Offering to administer the medication without proper assessment or consulting the provider is not appropriate and could potentially harm the client.

5. A client with hyperthyroidism is admitted to the postoperative unit after a subtotal thyroidectomy. Which of the client's serum laboratory values requires intervention by the nurse?

• A. Blood glucose 90 mg/dL
• B. Sodium 138 mEq/L
• C. Total calcium 5.0 mg/dL
• D. Potassium 4.2 mEq/L

Correct answer: C

Rationale: A total calcium level of 5.0 mg/dL is critically low and indicates possible hypocalcemia, a common complication after thyroid surgery. This condition can lead to tetany and requires immediate intervention. Blood glucose within normal range, sodium, and potassium levels are not indicative of an immediate postoperative complication like hypocalcemia in this case.

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