Nursing Elites

1. A client has a prescription for a Transcutaneous Electrical Nerve Stimulator (TENS) unit for pain management during the postoperative period following a Lumbar Laminectomy. What information should the nurse reinforce about the action of this adjuvant pain modality?

• A. Mild electrical stimulus on the skin surface closes the gates of nerve conduction for severe pain
• B. Pain perception in the cerebral cortex is dulled by the unit's discharge of an electrical stimulus
• C. An infusion of medication in the spinal canal will block pain perception
• D. The discharge of electricity will distract the client's focus on the pain

Correct answer: A

Rationale: The correct answer is A. TENS units work by delivering small electrical impulses through the skin. These impulses are thought to close the 'gates of nerve conduction,' which can help in managing severe pain. Choice B is incorrect because the dulled pain perception does not occur in the cerebral cortex by the TENS unit. Choice C is incorrect as it describes a different method of pain management involving medication in the spinal canal. Choice D is incorrect because TENS does not work by distracting the client's focus on pain, but rather by altering pain perception through electrical impulses.

2. A client with a diagnosis of pneumonia is experiencing difficulty expectorating thick secretions. What intervention should the nurse implement to assist the client?

• A. Administer antibiotics as prescribed.
• B. Encourage increased fluid intake.
• C. Perform chest physiotherapy.
• D. Provide humidified oxygen.

Correct answer: B

Rationale: Encouraging increased fluid intake is the appropriate intervention to assist the client with pneumonia who is having difficulty expectorating thick secretions. Adequate hydration helps to thin the secretions, making them easier to cough up. Administering antibiotics (Choice A) is important for treating the infection itself but does not directly address the thick secretions. Chest physiotherapy (Choice C) may be beneficial in some cases but is not the initial intervention for thick secretions. Providing humidified oxygen (Choice D) can help with oxygenation but does not directly address the problem of thick secretions.

3. What is the most important information the nurse should teach a diabetic client about foot care?

• A. Inspect feet daily
• B. Wear cotton socks
• C. Use lukewarm water to wash feet
• D. Cut nails straight across

Correct answer: A

Rationale: The correct answer is to inspect feet daily. For diabetic clients, daily foot inspection is crucial in preventing complications like infections and ulcers. By checking their feet regularly, clients can identify any issues early and seek appropriate medical care. The other choices are important aspects of foot care for diabetic clients but not as critical as daily foot inspections. Wearing cotton socks helps in moisture control, using lukewarm water to wash feet helps prevent skin damage, and cutting nails straight across prevents ingrown nails. However, daily foot inspection is the most vital as it allows for early detection of any potential problems, which is key in diabetic foot care.

4. The client is being educated by the nurse about the side effects of prednisone. Which side effect should the client be instructed to report immediately?

• A. Weight gain.
• B. Increased appetite.
• C. Hyperglycemia.
• D. Fever or sore throat.

Correct answer: D

Rationale: The correct answer is D: Fever or sore throat. These symptoms should be reported immediately as they could indicate an infection, which can be serious in clients taking prednisone due to its immunosuppressive effects. Choices A and B are common side effects of prednisone but are not typically considered urgent. Choice C, hyperglycemia, is a known side effect of prednisone but is not an immediate concern compared to the potential of an infection signaled by fever or sore throat.

5. The nurse is assessing a client with an IV infusion of normal saline. The client reports pain and swelling at the IV site. What should the nurse do first?

• A. Slow the rate of infusion
• B. Apply a warm compress to the site
• C. Elevate the affected arm
• D. Discontinue the IV infusion

Correct answer: D

Rationale: The correct answer is to discontinue the IV infusion. Pain and swelling at the IV site may indicate infiltration or phlebitis, which requires immediate discontinuation of the infusion to prevent further complications. Continuing the infusion can lead to tissue damage or infection. Slowing the rate of infusion, applying a warm compress, or elevating the affected arm would not address the underlying issue of infiltration or phlebitis and could potentially worsen the condition by allowing more fluid to infiltrate the tissues.

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