Nursing Elites

1. A client who recently had a hip replacement has a strong odor from the urine and bloody drainage on the surgical dressing. What should the nurse do first?

• A. Obtain a urine sample from the bedpan.
• B. Insert an indwelling urinary catheter.
• C. Measure the client's oral temperature.
• D. Remove dressing and assess surgical site.

Correct answer: C

Rationale: The correct answer is to measure the client's oral temperature. In this scenario, the strong odor from urine and bloody drainage on the surgical dressing are concerning signs that suggest a possible infection. Fever is a common sign of infection, so measuring the client's temperature will help confirm if an infection is present. Obtaining a urine sample, inserting an indwelling urinary catheter, or removing the dressing and assessing the surgical site are not the first priority actions when infection is suspected. These actions may be necessary later but assessing the client's temperature is the initial step to evaluate for infection.

2. The nurse assesses a client’s wound. What type of wound requires immediate intervention by the nurse?

• A. Laceration
• B. Abrasion
• C. Contusion
• D. Ulceration

Correct answer: A

Rationale: Lacerations, especially deep ones, are prone to bacterial contamination and may require immediate intervention to prevent infection. Abrasions, contusions, and ulcerations are not as likely to lead to immediate serious complications like infections as lacerations.

3. A client with type 1 diabetes is found unconscious with a blood glucose of 40 mg/dL. What is the nurse's priority intervention?

• A. Administer a 50% dextrose bolus intravenously.
• B. Administer glucagon intramuscularly.
• C. Provide oral glucose gel.
• D. Recheck the blood glucose level in 15 minutes.

Correct answer: A

Rationale: The correct answer is to administer a 50% dextrose bolus intravenously. In unconscious clients with hypoglycemia, IV dextrose rapidly raises the blood glucose level. Glucagon would be a slower option and is typically used if IV access is unavailable. Oral glucose gel is not appropriate for an unconscious client as it requires swallowing and may cause aspiration. Rechecking the blood glucose level in 15 minutes delays immediate treatment and could lead to further deterioration.

4. A client in heart failure (HF) presents with weakness and poor urine output. Which assessment finding requires immediate action?

• A. Heart rate of 122 bpm and respiratory rate of 28.
• B. Yellow sputum expectorated.
• C. Temperature of 100.5°F (38.1°C).
• D. Shortness of breath on exertion.

Correct answer: C

Rationale: An elevated temperature may indicate infection and should be treated immediately in a client with heart failure.

5. A female client experiences a sudden loss of consciousness and is taken to the emergency department. Initial assessment indicates her blood glucose level is critically low. Once stabilized, she reports being treated for anorexia nervosa. What intervention is most important for the nurse to include in the client’s discharge plan?

• A. Encourage a high-protein, low-carbohydrate diet.
• B. Encourage her to join a group focusing on self-esteem.
• C. Schedule an outpatient psychosocial assessment.
• D. Teach relaxation techniques to manage stress.

Correct answer: B

Rationale: Joining a group that focuses on self-esteem is the most important intervention for the nurse to include in the client's discharge plan. This can help the client address underlying emotional issues related to her anorexia nervosa and improve her mental health. Choice A is incorrect because a high-protein, low-carbohydrate diet may not address the psychological factors contributing to anorexia nervosa. Choice C is incorrect as scheduling an outpatient psychosocial assessment is important but not the most crucial intervention for discharge planning in this case. Choice D is also not the priority as teaching relaxation techniques, although beneficial, may not directly address the self-esteem and emotional issues that need to be tackled in this situation.

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