Nursing Elites

1. A client with a postoperative wound that eviscerated yesterday has an elevated temperature. Which intervention is most important for the nurse to implement?

• A. Initiate contact isolation.
• B. Obtain a wound swab for culture and sensitivity.
• C. Assess temperature every 4 hours.
• D. Use alcohol-based solutions for hand hygiene.

Correct answer: B

Rationale: In this scenario, the most critical intervention is to obtain a wound swab for culture and sensitivity. This will help identify the causative organism present in the wound, enabling healthcare providers to prescribe the appropriate treatment. Initiating contact isolation (Choice A) may be necessary in certain situations but is not the priority in this case where infection is suspected. Assessing the temperature (Choice C) is important for monitoring the client's condition but does not address the underlying cause. Using alcohol-based solutions for hand hygiene (Choice D) is a standard practice for infection control but does not directly address the client's specific condition of a postoperative wound with evisceration and elevated temperature.

2. A male client with ulcerative colitis received a prescription for a corticosteroid last month, but because of the side effects, he stopped taking the medication 6 days ago. Which finding warrants immediate intervention by the nurse?

• A. Anxiety and restlessness
• B. Increased bowel movements
• C. Abdominal cramping
• D. Fever and chills

Correct answer: A

Rationale: The correct answer is A: Anxiety and restlessness. Abruptly stopping corticosteroids can cause adrenal insufficiency, leading to symptoms such as anxiety and restlessness. These symptoms indicate a potential serious complication that requires immediate intervention. Increased bowel movements and abdominal cramping are common side effects of ulcerative colitis and may not warrant immediate intervention. Fever and chills are not typically associated with adrenal insufficiency caused by corticosteroid withdrawal.

3. Which nursing intervention has the highest priority for a multigravida who delivered twins and is at risk for postpartum hemorrhage?

• A. Maintain cold packs on the perineum for 24 hours.
• B. Assess the client's pain level frequently.
• C. Observe for appropriate interaction with the infants.
• D. Assess fundal tone and lochia flow.

Correct answer: D

Rationale: Assessing fundal tone and lochia flow is crucial in the early detection and prevention of postpartum hemorrhage. Fundal tone helps identify uterine atony, a common cause of postpartum hemorrhage, while monitoring lochia flow can indicate excessive bleeding. Cold packs on the perineum, although helpful for pain and swelling, are not the priority in this situation. Pain assessment and observing interactions with infants are important but secondary to assessing for signs of postpartum hemorrhage.

4. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which intervention should the nurse implement first?

• A. Elevate the head of the bed.
• B. Administer oxygen therapy as prescribed.
• C. Assess the client's oxygen saturation.
• D. Obtain an arterial blood gas (ABG) sample.

Correct answer: C

Rationale: Assessing the client's oxygen saturation is the first priority in managing a client with COPD receiving supplemental oxygen to ensure adequate oxygenation. Monitoring oxygen saturation levels helps in determining the effectiveness of the oxygen therapy and if adjustments are needed. Elevating the head of the bed can help with breathing but is not the first priority. Administering oxygen therapy as prescribed is important, but assessing the current oxygen saturation comes before administering more oxygen. Obtaining an arterial blood gas (ABG) sample may provide valuable information, but it is not the initial intervention needed in this situation.

5. An 11-year-old client is admitted to the mental health unit after trying to run away from home and threatening self-harm. The nurse establishes a goal to promote effective coping and plans to ask the client to verbalize three ways to deal with stress. Which activity is best to establish rapport and accomplish this therapeutic goal?

• A. Play a board game with the client and begin talking about stressors
• B. Conduct a formal therapy session
• C. Ask the client to write down their feelings
• D. Have a group discussion about stress management

Correct answer: A

Rationale: Playing a board game with the client and initiating a conversation about stressors is the best choice to establish rapport and achieve the therapeutic goal of helping the client verbalize ways to cope with stress. Board games provide a relaxed and non-threatening environment, allowing the client to feel more comfortable and open up about their stressors. Choice B, conducting a formal therapy session, might be too structured and intimidating for the client, hindering open communication. Choice C, asking the client to write down their feelings, lacks the interactive and engaging aspect that a board game provides. Choice D, having a group discussion about stress management, may not be as effective initially as one-on-one interaction to build trust and rapport with the client.

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