Nursing Elites

1. A client scheduled for abdominal surgery reports being worried. Which of the following actions should the nurse take?

• A. Offer information on a relaxation technique and ask if the client is interested in trying it.
• B. Request a social worker to see the client to discuss meditation.
• C. Attempt to use biofeedback techniques with the client.
• D. Tell the client many people feel the same way before surgery and to think of something else.

Correct answer: A

Rationale: Offering relaxation techniques addresses the client's immediate concern by providing a proactive approach to managing anxiety. It shows empathy and offers a practical solution. Requesting a social worker for meditation (Choice B) may not be the most direct response to the client's immediate worry. Attempting biofeedback (Choice C) may not be suitable without the client's interest or consent. Telling the client to think of something else (Choice D) dismisses the client's feelings and does not provide constructive support.

2. The healthcare provider is caring for a client with a history of hypertension. Which assessment finding would be most concerning?

• A. Blood pressure of 150/90 mmHg
• B. Irregular heart rate
• C. Shortness of breath
• D. Headache

Correct answer: C

Rationale: Shortness of breath in a client with a history of hypertension is a critical assessment finding as it may indicate heart failure, pulmonary edema, or other severe complications. The development of shortness of breath suggests that the client's condition may be rapidly deteriorating and requires immediate medical attention. Elevated blood pressure (150/90 mmHg) is concerning but not as acute as the potential complications associated with shortness of breath. An irregular heart rate and headache can also be symptoms of hypertension, but in this scenario, shortness of breath poses a higher risk of severe cardiovascular or respiratory issues.

3. The healthcare provider is assessing a client diagnosed with rheumatoid arthritis. Which assessment finding would be most concerning?

• A. Morning stiffness
• B. Joint deformities
• C. Weight loss
• D. Fever

Correct answer: D

Rationale: Fever in a client with rheumatoid arthritis can indicate an underlying infection or a more serious systemic involvement, such as vasculitis or inflammation of internal organs. These conditions can lead to serious complications and require immediate medical attention. Joint deformities and morning stiffness are common manifestations of rheumatoid arthritis itself and may not be indicative of an acute issue. Weight loss can be seen in chronic inflammatory conditions like rheumatoid arthritis but is not as concerning as fever, which suggests an acute process requiring prompt evaluation and intervention.

4. A client with a history of atrial fibrillation is prescribed warfarin (Coumadin). Which statement by the client indicates a need for further teaching?

• A. I will avoid foods high in vitamin K.
• B. I will take my medication at the same time every day.
• C. I will use a soft toothbrush to prevent gum bleeding.
• D. I can take aspirin if I have a headache.

Correct answer: D

Rationale: The correct answer is 'D: I can take aspirin if I have a headache.' This statement indicates a need for further teaching because aspirin can increase the risk of bleeding in clients taking warfarin. Clients on warfarin therapy should avoid taking aspirin or any other medications that can increase the risk of bleeding without consulting their healthcare provider. Choices A, B, and C are correct statements that demonstrate understanding of warfarin therapy and its potential side effects. Avoiding foods high in vitamin K helps maintain the effectiveness of warfarin, taking medication at the same time every day ensures consistent therapeutic levels, and using a soft toothbrush helps prevent gum bleeding, which can be a side effect of warfarin therapy.

5. The LPN/LVN observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first?

• A. Observe the appearance of the skin under the ice pack.
• B. Instruct the client regarding the importance of the covering.
• C. Reapply the covering after filling it with fresh ice.
• D. Ask the client how long the ice pack was applied to the skin.

Correct answer: A

Rationale: The correct first action for the nurse to take when a client removes the covering from an ice pack is to observe the appearance of the skin under the ice pack. This assessment is crucial to check for any skin damage or adverse reactions resulting from direct contact with the ice pack. Instructing the client about the importance of the covering (Choice B) can follow the skin assessment. Reapplying the covering (Choice C) before skin assessment may potentially cause harm. Asking the client about the duration of ice application (Choice D) is not the immediate priority; ensuring skin integrity is the primary concern.

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