Nursing Elites

1. A client is admitted with a diagnosis of myocardial infarction (MI). Which intervention is a priority during the acute phase?

• A. Administer morphine for pain relief
• B. Encourage the client to perform isometric exercises
• C. Position the client flat in bed
• D. Restrict fluid intake

Correct answer: A

Rationale: During the acute phase of a myocardial infarction (MI), the priority intervention is to administer morphine for pain relief. Morphine not only alleviates pain but also reduces myocardial oxygen demand, which is crucial in the management of MI. Encouraging the client to perform isometric exercises (choice B) can increase myocardial oxygen demand and should be avoided during the acute phase. Positioning the client flat in bed (choice C) may worsen symptoms by increasing venous return and workload on the heart. Restricting fluid intake (choice D) is not a priority intervention during the acute phase of MI; maintaining adequate hydration is important for organ perfusion.

2. A client with a diagnosis of deep vein thrombosis (DVT) is receiving anticoagulant therapy. Which instruction should the nurse provide to the client?

• A. Avoid walking as much as possible
• B. Report any signs of bleeding to the healthcare provider
• C. Take aspirin for additional pain relief
• D. Wear compression stockings at night

Correct answer: B

Rationale: Reporting signs of bleeding is essential while on anticoagulant therapy to prevent complications.

3. While caring for a client's postoperative dressing, the nurse observes purulent wound drainage. Previously, the wound was inflamed and tender but without drainage. Which is the most important action for the nurse to take?

• A. Determine if the drainage has an unpleasant odor.
• B. Monitor the client's white blood cell count (WBC).
• C. Request a culture and sensitivity of the wound.
• D. Cleanse the wound with a sterile saline solution.

Correct answer: C

Rationale: Requesting a culture and sensitivity of the wound is the most crucial action in this scenario. This will help identify the specific organism causing the infection and determine its sensitivity to antibiotics, guiding appropriate antibiotic therapy. Option A is less critical as odor alone may not provide enough information about the type of infection. Monitoring the client's white blood cell count (WBC) in option B is important but not as immediate as obtaining a wound culture. Cleansing the wound with a sterile saline solution in option D is necessary but should follow after obtaining the culture results to ensure proper treatment.

4. The nurse is caring for a client who underwent a total knee replacement yesterday. What activity level should the nurse encourage today?

• A. Bed rest with bathroom privileges only
• B. Frequent, short walks with assistance
• C. Range of motion exercises to the knee every four hours
• D. Leg elevation to reduce swelling

Correct answer: B

Rationale: After a total knee replacement, early ambulation is crucial for promoting circulation and preventing complications like thrombosis. Bed rest should be avoided as it can increase the risk of complications. Range of motion exercises are important but should be performed gradually and not excessively. Leg elevation is beneficial for reducing swelling but should not be the primary activity level encouraged immediately after surgery.

5. A client requires application of an eye shield to the right eye. What should the nurse do in order to apply tape to anchor the shield most effectively?

• A. Place tape from the cheek to the forehead
• B. Secure tape from the nose to the ear
• C. Attach tape from the lower eyelid to the upper forehead
• D. Use circular bandaging around the head

Correct answer: C

Rationale: The correct way to apply tape to anchor an eye shield effectively is to attach the tape from the lower eyelid to the upper forehead. This method provides stability for the shield without putting pressure on the eye itself, thus helping to protect the eye. Choices A, B, and D are incorrect because taping from the cheek to the forehead, securing tape from the nose to the ear, or using circular bandaging around the head may not provide the necessary stability and protection required for the eye shield.

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