Nursing Elites

1. A client undergoing surgery refuses to remove religious jewelry. What is the best course of action?

• A. Proceed with surgery while securing the jewelry to the patient.
• B. Remove the jewelry and document the removal.
• C. Document the refusal and delay the surgery.
• D. Remove the jewelry with the family's permission.

Correct answer: B

Rationale: The correct course of action is to remove the jewelry and document the removal. While religious beliefs should be respected, ensuring patient safety during surgery is crucial. Securing the jewelry may not be sufficient to prevent any interference during the surgical procedure. Documenting the removal is important for legal and documentation purposes. Delaying the surgery or removing the jewelry with the family's permission may not be the best options as patient safety should be the top priority in this situation.

2. A nurse is providing teaching to a parent of a child with celiac disease. Which food choice should the nurse include?

• A. Rice
• B. Barley
• C. Wheat
• D. Rye

Correct answer: A

Rationale: The correct answer is A, Rice. In celiac disease, individuals must avoid gluten-containing foods. Rice is a safe option as it is gluten-free. Barley (choice B), Wheat (choice C), and Rye (choice D) all contain gluten and should be avoided in a celiac diet. Therefore, the nurse should emphasize including rice in the child's diet.

3. Which intervention is most effective in preventing deep vein thrombosis (DVT) in a postoperative patient?

• A. Encourage the patient to drink plenty of fluids.
• B. Encourage early ambulation and leg exercises.
• C. Administer anticoagulants as prescribed.
• D. Apply compression stockings to the patient's legs.

Correct answer: B

Rationale: The most effective intervention in preventing deep vein thrombosis (DVT) in a postoperative patient is to encourage early ambulation and leg exercises. Early ambulation helps promote circulation, preventing stasis and reducing the risk of blood clot formation. Encouraging the patient to drink plenty of fluids (choice A) is important for overall health but is not the most effective intervention for preventing DVT. Administering anticoagulants (choice C) is a valuable intervention in some cases, but it may not be suitable for all postoperative patients. Applying compression stockings (choice D) can help prevent DVT but is generally not as effective as early ambulation and leg exercises in postoperative patients.

4. A patient is admitted with suspected pneumonia. What is the nurse's priority assessment?

• A. Auscultate the patient's lung sounds.
• B. Assess the patient's oxygen saturation.
• C. Monitor the patient's white blood cell count.
• D. Monitor the patient's skin integrity.

Correct answer: B

Rationale: The correct answer is to assess the patient's oxygen saturation. In suspected pneumonia, ensuring adequate oxygenation is critical to monitor respiratory function. Auscultating lung sounds is important but assessing oxygen saturation takes precedence as it directly reflects the patient's oxygen levels. Monitoring white blood cell count is more related to infection assessment rather than immediate respiratory status. Checking skin integrity is essential for overall patient care but is not the priority in a patient with suspected pneumonia.

5. A patient with severe pain and leg swelling is admitted. What should the nurse assess for?

• A. Check for signs of deep vein thrombosis.
• B. Assess for compartment syndrome.
• C. Increase the patient's fluid intake.
• D. Prepare the patient for surgery to relieve pain.

Correct answer: B

Rationale: When a patient presents with severe pain and leg swelling, the nurse should assess for compartment syndrome. Compartment syndrome is a serious condition that can develop due to increased pressure within a muscle compartment, leading to compromised circulation and potential tissue damage. It is crucial to identify compartment syndrome promptly as it may require immediate intervention to prevent further complications. Checking for signs of deep vein thrombosis (Choice A) is also important in a patient with leg swelling, but in this scenario, the focus should be on assessing for compartment syndrome due to the severity of the symptoms. Increasing fluid intake (Choice C) may not address the underlying cause of the patient's symptoms. Preparing the patient for surgery (Choice D) without a comprehensive assessment and diagnosis is premature and may not be the appropriate initial intervention.

Similar Questions