Nursing Elites

1. The patient is admitted to a skilled care unit for rehabilitation after the surgical procedure of fixation of a fractured left hip. The patient's nursing diagnosis is Impaired physical mobility related to musculoskeletal impairment from surgery and pain with movement. The patient is able to use a walker but needs assistance ambulating and transferring from the bed to the chair. Which nursing intervention is most appropriate for this patient?

• A. Obtain assistance and physically transfer the patient to the chair.
• B. Assist with ambulation and measure how far the patient walks.
• C. Give pain medication after ambulation so the patient will have a clear mind.
• D. Bring the patient to the cafeteria for group instruction on ambulation.

Correct answer: B

Rationale: The most appropriate nursing intervention for this patient is to assist with ambulation and measure how far the patient walks. This intervention helps quantify the patient's progress in mobility and rehabilitation. Choice A is incorrect because physically transferring the patient does not focus on promoting independence or assessing progress. Choice C is inappropriate as pain medication should be given based on scheduled times or as needed, not specifically after ambulation. Choice D is not suitable as group instruction on ambulation is not as individualized or focused on the patient's current needs and abilities.

2. A 3-year-old child has had multiple tooth extractions while under general anesthesia. The client returns from the post-anesthesia care unit crying but awake. Which approach is likely to be successful?

• A. Examine the mouth first
• B. Reassure the child
• C. Examine the mouth last
• D. Offer a pacifier

Correct answer: C

Rationale: In this scenario, it is crucial to prioritize the comfort of the child. By examining the mouth last, discomfort is minimized, and the child is given the opportunity to settle down. Choosing to examine the mouth first may escalate the distress of the child further. While reassuring the child is important, in this case, addressing the physical discomfort before providing emotional reassurance is more effective. Offering a pacifier may provide some comfort, but addressing the immediate physical discomfort by examining the mouth last is the most appropriate action to help the child settle down after the procedure.

3. During a peripheral vascular assessment, a healthcare professional places the bell of the stethoscope on a client's neck and hears an audible vascular sound associated with turbulent blood flow. This sound indicates which of the following?

• A. Narrowed arterial lumen
• B. Distended jugular veins
• C. Impaired ventricular contraction
• D. Asynchronous closure of the aortic and pulmonic valve

Correct answer: A

Rationale: The correct answer is A: Narrowed arterial lumen. Arterial bruits are abnormal sounds caused by turbulent blood flow through narrowed or occluded arteries. This turbulent flow creates a blowing sound, which is heard as an arterial bruit. Distended jugular veins (choice B) are typically associated with venous issues, not arterial abnormalities. Impaired ventricular contraction (choice C) and asynchronous closure of the aortic and pulmonic valve (choice D) are not directly related to the audible vascular sound described in the scenario.

4. A nurse in an outpatient surgical center is admitting a client for a laparoscopic procedure. The client has a prescription for preoperative diazepam. Prior to administering the medication, which of the following actions is the nurse’s priority?

• A. Teaching the client about the purpose of the medication
• B. Giving the medication at the administration time the provider prescribed
• C. Identifying the client’s medication allergies
• D. Documenting the client’s anxiety level

Correct answer: C

Rationale: The correct answer is C: Identifying the client's medication allergies. This is the priority action before administering any medication to prevent allergic reactions or adverse effects. Teaching the client about the medication's purpose is important for client understanding but not as critical as ensuring the absence of allergies. While giving medication at the prescribed time is crucial, verifying allergies takes precedence to ensure patient safety. Documenting the client's anxiety level is relevant for holistic care but is not the priority compared to ensuring safe medication administration.

5. A client is demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client?

• A. The client reports severe pain
• B. The client asks for a demonstration
• C. The client inquires about potential complications
• D. The client agrees to the procedure

Correct answer: A

Rationale: The correct answer is A because severe pain can hinder the client's ability to participate effectively in learning. Pain can be distracting and may prevent the client from focusing on acquiring new information or skills. Choice B is incorrect because asking for a demonstration shows an interest in learning and readiness to understand the exercises. Choice C is incorrect as inquiring about potential complications indicates the client's engagement in understanding the procedure and its outcomes, demonstrating readiness to learn. Choice D is incorrect as agreeing to the procedure does not necessarily reflect a lack of readiness to learn. The client may still be open to receiving information about postoperative care, indicating a level of readiness to learn despite agreeing to the surgery.

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