Nursing Elites

1. The nurse notes that a postoperative client's wound site is red and slightly swollen. What is the most appropriate action?

• A. Apply an ice pack
• B. Document the findings and monitor
• C. Notify the surgeon
• D. Clean the wound with sterile saline

Correct answer: C

Rationale: The correct answer is to notify the surgeon. Redness and swelling at a wound site can indicate an infection, which may require medical intervention. Applying an ice pack (choice A) is not appropriate without further assessment. While documenting the findings and monitoring (choice B) is important, it should be accompanied by notifying the surgeon for further evaluation. Cleaning the wound with sterile saline (choice D) may not be sufficient if an infection is present, so immediate communication with the surgeon is crucial.

2. A client with type 1 diabetes is experiencing symptoms of hypoglycemia. What is the nurse's priority intervention?

• A. Administer glucagon intramuscularly
• B. Provide a complex carbohydrate snack
• C. Administer 50% dextrose intravenously
• D. Give 15 grams of a fast-acting carbohydrate

Correct answer: D

Rationale: The priority intervention for a client with type 1 diabetes experiencing symptoms of hypoglycemia is to give 15 grams of a fast-acting carbohydrate. In a hypoglycemic state, the priority is to quickly raise the blood glucose level. Administering glucagon intramuscularly (Choice A) is reserved for severe hypoglycemia when the client is unable to take oral carbohydrates. Providing a complex carbohydrate snack (Choice B) is beneficial after the initial treatment of hypoglycemia to prevent recurrence. Administering 50% dextrose intravenously (Choice C) is a more invasive intervention typically done in a hospital setting for severe cases.

3. The unlicensed assistive personnel (UAP) reports to the nurse that a client refused to bathe for the third consecutive day. What action is best for the nurse to take?

• A. Ask the client why the bath was refused
• B. Ask family members to encourage the client to bathe
• C. Explain the importance of good hygiene to the client
• D. Reschedule the bath for the following day

Correct answer: A

Rationale: The correct action for the nurse to take is to ask the client why the bath was refused. Understanding the client's reasons for refusal can guide appropriate interventions, respecting client autonomy while addressing any underlying issues. Choice B is not the best course of action as involving family members may not address the client's specific concerns. Choice C, while important, may not directly address the immediate refusal to bathe. Choice D does not address the underlying reasons for the refusal and may not lead to a resolution.

4. The nurse is caring for a client with acute pancreatitis. Which intervention should be included in the plan of care?

• A. Provide a high-protein diet
• B. Encourage oral fluids
• C. Administer intravenous fluids as prescribed
• D. Monitor for signs of hyperglycemia

Correct answer: C

Rationale: The correct intervention to include in the plan of care for a client with acute pancreatitis is to administer intravenous fluids as prescribed. Intravenous fluids are crucial to maintain hydration and electrolyte balance in clients with acute pancreatitis. Providing a high-protein diet (Choice A) is not recommended initially for clients with acute pancreatitis, as they may need to be kept NPO (nothing by mouth) to rest the pancreas. Encouraging oral fluids (Choice B) may not be appropriate if the client is experiencing severe symptoms and requires intravenous fluids. Monitoring for signs of hyperglycemia (Choice D) is important but not the immediate intervention needed to address the fluid and electrolyte imbalances associated with acute pancreatitis.

5. When providing care for a client receiving palliative care for terminal cancer, what should the nurse prioritize?

• A. Pain management
• B. Arranging family visits
• C. Discussing advance directives
• D. Providing nutritional support

Correct answer: A

Rationale: When caring for a client receiving palliative care for terminal cancer, the nurse should prioritize pain management. Effective pain management is crucial in enhancing the quality of life for terminally ill patients. While arranging family visits and discussing advance directives are important aspects of care, pain management takes precedence in providing comfort and alleviating suffering. Nutritional support is essential but may be of lesser priority compared to pain management in this context.

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