Nursing Elites

1. A client with peripheral neuropathy due to cirrhosis is at risk for injury. What should the nurse do?

• A. Protect the client's feet from injury
• B. Apply a heating pad to the affected area
• C. Keep the client's feet elevated
• D. Assess the feet and legs for jaundice

Correct answer: A

Rationale: Protecting the client's feet from injury is critical as peripheral neuropathy can lead to decreased sensation and increased risk of trauma. This measure helps prevent wounds, ulcers, and other complications. Applying a heating pad (Choice B) can worsen symptoms and cause burns due to decreased sensation. Keeping the client's feet elevated (Choice C) may help reduce swelling but does not directly address the risk of injury. Assessing for jaundice (Choice D) is important in cirrhosis but is not directly related to the client's risk of injury due to peripheral neuropathy.

2. The PN identifies an electrolyte imbalance, exhibited by changes in mental status, and an elevated blood pressure for a client with progressive heart disease. Which intervention should the PN implement first?

• A. Record usual eating patterns
• B. Evaluate for muscle cramping
• C. Document abdominal girth
• D. Elevate both legs on pillows

Correct answer: B

Rationale: Evaluating for muscle cramping, which is a sign of electrolyte imbalance, is crucial in this scenario. Electrolyte imbalances, especially involving potassium or calcium, can lead to serious complications such as arrhythmias or seizures, which need immediate attention. Recording eating patterns (choice A) may be important for overall assessment but is not the priority in this situation. Documenting abdominal girth (choice C) and elevating legs on pillows (choice D) are not directly related to addressing the immediate concern of electrolyte imbalance and its potential complications.

3. A nurse who receives a patient in the operative suite prior to the actual surgery is in charge of the patient’s care. Which of the following is NOT a task related to the nurse’s intraoperative care?

• A. Go over the surgical procedure with the patient before he or she is anesthetized
• B. Strictly adhere to asepsis during all intraoperative procedures
• C. Provide emotional support to the patient and their family
• D. Monitor the patient’s physical status

Correct answer: A

Rationale: The correct answer is A. Going over the surgical procedure with the patient is typically done preoperatively, not intraoperatively. Intraoperative tasks of a nurse involve strictly adhering to asepsis during procedures, monitoring the patient's physical status, and providing emotional support to the patient and their family during the surgery. Choices B, C, and D are all tasks that are directly related to the nurse's responsibilities during the intraoperative phase of care.

4. The nurse is assisting with the admission of a young adult female Korean exchange student with acute abdominal pain. Although the client has been able to easily answer questions, when asked about sexual activity, she looks away. What action should the nurse take?

• A. Omit the section of the assessment form
• B. Ask her if she would like an interpreter to help her understand the question
• C. Reword the question to make it more culturally sensitive
• D. Observe the client's response when asked a different question

Correct answer: D

Rationale: Observing the client's response to another question is the most appropriate action in this scenario. By doing so, the nurse can assess whether the client's discomfort is due to cultural sensitivity or a misunderstanding. This approach allows the nurse to proceed with sensitivity and respect, ensuring effective communication. Option A is incorrect because omitting the section of the assessment form may result in missing crucial information relevant to the client's condition. Option B jumps to assumptions about a language barrier without confirming it first. Option C focuses on rewording the question without addressing the underlying issue causing the client's discomfort, which may not necessarily be due to a lack of understanding.

5. Which of the following is a primary intervention for a patient experiencing hypoglycemia?

• A. Administering insulin
• B. Providing a complex carbohydrate meal
• C. Giving 15 grams of a fast-acting carbohydrate, like glucose tablets
• D. Encouraging the patient to exercise

Correct answer: C

Rationale: Giving 15 grams of a fast-acting carbohydrate, such as glucose tablets, is the primary intervention for hypoglycemia. This rapid-acting carbohydrate helps quickly raise blood sugar levels, providing immediate relief to the patient. Administering insulin (Choice A) would further lower blood sugar levels, exacerbating the hypoglycemia. Providing a complex carbohydrate meal (Choice B) would not act quickly enough to address the immediate low blood sugar issue. Encouraging the patient to exercise (Choice D) is inappropriate during hypoglycemia as it can further deplete glucose levels.

Similar Questions