Nursing Elites

1. A client presents to the clinic with a large abscess on the right thigh. The healthcare provider incises and drains the abscess. Which instruction should the nurse provide to the client upon discharge?

• A. Avoid showering until the wound is completely closed
• B. Perform daily wound care and dressing changes
• C. Apply heat to the wound for 15 minutes twice a day
• D. Take the prescribed antibiotic until the wound is fully healed

Correct answer: B

Rationale: After incision and drainage of an abscess, it is crucial to perform daily wound care and dressing changes to prevent infection and promote healing. Avoiding showering until the wound is completely closed (choice A) may not be practical or necessary. Applying heat to the wound (choice C) can increase the risk of infection and delay healing. While taking the prescribed antibiotic (choice D) is important, wound care and dressing changes are more directly related to promoting healing and preventing complications.

2. A client on long-term corticosteroid therapy for rheumatoid arthritis presents with weakness and hypotension. What is the nurse's first action?

• A. Administer a PRN dose of corticosteroids.
• B. Place the client in a supine position.
• C. Encourage oral fluid intake.
• D. Review the client's recent medication history.

Correct answer: A

Rationale: Administering a PRN dose of corticosteroids is the correct first action when a client on long-term corticosteroid therapy presents with weakness and hypotension. In this scenario, the client is likely experiencing adrenal insufficiency due to prolonged corticosteroid use. Administering corticosteroids promptly can help correct this insufficiency and improve the client's symptoms. Placing the client in a supine position may be necessary for symptomatic hypotension, but addressing the root cause with corticosteroids is more crucial initially. Encouraging oral fluid intake is important for many conditions but is not the priority in this case. Reviewing the client's recent medication history can provide valuable information but is not the first action needed to address the client's current presentation.

3. Why is it important for the healthcare provider to monitor blood pressure in clients receiving antipsychotic drugs?

• A. Orthostatic hypotension is a common side effect.
• B. Most antipsychotic drugs cause elevated blood pressure.
• C. This provides information on the amount of sodium allowed in the diet.
• D. It will indicate the need to institute antiparkinsonian drugs.

Correct answer: A

Rationale: Corrected Question: Monitoring blood pressure in clients receiving antipsychotic drugs is crucial because orthostatic hypotension is a common side effect. Orthostatic hypotension can lead to a sudden drop in blood pressure upon standing, increasing the risk of falls and related injuries. Therefore, regular blood pressure monitoring helps healthcare providers detect and manage this potential side effect. Incorrect Choices Rationale: - Choice B is incorrect because while antipsychotic drugs can have various side effects, causing elevated blood pressure is not a common effect associated with them. - Choice C is unrelated to blood pressure monitoring in clients receiving antipsychotic drugs. Monitoring blood pressure in this context aims to detect and manage side effects of the medication, not to assess sodium intake. - Choice D is incorrect as monitoring blood pressure in clients receiving antipsychotic drugs is primarily aimed at detecting orthostatic hypotension, not as an indicator for instituting antiparkinsonian drugs.

4. An adolescent client with intellectual disability refuses oral hygiene. A behavior modification program is recommended. Which reinforcement is best for the nurse to implement?

• A. Candy for successful oral hygiene tasks.
• B. Tokens for each successful oral hygiene task.
• C. Privilege restrictions for refusing oral hygiene tasks.
• D. Preferred activities or privileges for compliance.

Correct answer: D

Rationale: In this scenario, the best reinforcement for the nurse to implement is preferred activities or privileges for compliance. Positive reinforcement with privileges is effective in encouraging behavior change in adolescents, including those with intellectual disabilities. Choice A (Candy for successful oral hygiene tasks) may not be suitable as it involves providing a sugary reward, which contradicts the goal of oral hygiene. Choice B (Tokens for each successful oral hygiene task) could be effective but may not be as motivating as preferred activities or privileges. Choice C (Privilege restrictions for refusing oral hygiene tasks) focuses on negative reinforcement, which is not as effective as positive reinforcement in behavior modification.

5. A client receiving total parenteral nutrition (TPN) reports nausea and dizziness. What action should the nurse take first?

• A. Check the client's blood glucose level.
• B. Check the client's vital signs and blood pressure.
• C. Decrease the infusion rate of TPN.
• D. Administer antiemetic medication as prescribed.

Correct answer: B

Rationale: When a client receiving total parenteral nutrition (TPN) reports symptoms like nausea and dizziness, the first action the nurse should take is to check the client's vital signs and blood pressure. This assessment helps determine the client's overall stability and can provide crucial information to guide further interventions. Checking the blood glucose level (Choice A) may be relevant but is not the priority in this situation. Decreasing the infusion rate of TPN (Choice C) may be necessary but should be based on assessment findings. Administering antiemetic medication (Choice D) should not be the initial action without first assessing the client's vital signs.

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