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. The client with high blood pressure is being taught by the nurse to avoid adding salt during cooking. What effect does sodium have on blood pressure?

• A. It decreases the viscosity of blood
• B. It leads to increased fluid retention
• C. It causes vasoconstriction of the blood vessels
• D. It enhances the excretion of potassium

Correct answer: C

Rationale: The correct answer is C: 'It causes vasoconstriction of the blood vessels.' Sodium can lead to vasoconstriction, which narrows the blood vessels, increasing resistance to blood flow and subsequently raising blood pressure. Choices A, B, and D are incorrect. Sodium does not decrease blood viscosity, but it can lead to fluid retention, which increases blood volume and pressure. It does not enhance the excretion of potassium; instead, high sodium intake can lead to potassium excretion by the kidneys.

3. A client with a diagnosis of tuberculosis (TB) is being discharged home. Which instruction is most important for the nurse to provide?

• A. Avoid close contact with others until treatment is complete.
• B. Take all prescribed medications as directed.
• C. Schedule a follow-up appointment with the healthcare provider.
• D. Wear a mask when in public places.

Correct answer: B

Rationale: The most important instruction for a client with tuberculosis (TB) is to take all prescribed medications as directed. This is crucial to prevent the development of drug-resistant TB. While avoiding close contact with others until treatment is complete (Choice A) is important to prevent the spread of TB, ensuring the client completes the prescribed medication regimen is the priority. Scheduling a follow-up appointment (Choice C) is important for monitoring but not as critical as medication adherence. Wearing a mask in public places (Choice D) can help reduce the spread of TB but is not as essential as taking medications as prescribed.

4. The nurse is preparing to administer a tuberculin skin test (TST). Which area of the body is the preferred site for this injection?

• A. Deltoid muscle
• B. Inner forearm
• C. Abdomen
• D. Thigh

Correct answer: B

Rationale: The inner forearm is the preferred site for administering a tuberculin skin test (TST) due to its easy accessibility, minimal hair interference, and good visibility of the injection site, allowing for accurate interpretation of the test results. The deltoid muscle, abdomen, and thigh are not preferred sites for a TST as they may not provide the optimal conditions required for the test. The deltoid muscle is commonly used for intramuscular injections, the abdomen may have varying subcutaneous fat thickness affecting the test, and the thigh may not provide the necessary visibility for accurate reading.

5. The nurse is caring for a client who has just received a blood transfusion. The client reports chills and back pain. What is the nurse's priority action?

• A. Slow down the rate of the transfusion
• B. Administer an antipyretic
• C. Stop the transfusion immediately
• D. Notify the healthcare provider

Correct answer: C

Rationale: Chills and back pain are signs of a possible transfusion reaction, which can indicate severe complications like a hemolytic reaction or sepsis. The priority action for the nurse is to stop the transfusion immediately to prevent further harm to the client. Slowing the rate of the transfusion or administering an antipyretic will not address the underlying cause of the reaction and could potentially worsen the client's condition. Notifying the healthcare provider should be done after ensuring the client's immediate safety by stopping the transfusion.

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