Nursing Elites

1. A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of the following manifestations requires immediate action by the nurse?

• A. Increase in frequency of swallowing.
• B. Moderate sanguineous drainage on the drip pad.
• C. Bruising to the face.
• D. Absent gag reflex.

Correct answer: A

Rationale: The correct answer is A: Increase in frequency of swallowing. After rhinoplasty, an increase in frequency of swallowing may indicate possible bleeding, which requires immediate action by the nurse. The client could be experiencing postoperative bleeding, and prompt intervention is necessary to prevent complications. Choice B, moderate sanguineous drainage on the drip pad, is expected in the immediate postoperative period and does not require immediate action unless it becomes excessive. Choice C, bruising to the face, is a common postoperative finding and does not require immediate action unless it is excessive or affects the airway. Choice D, absent gag reflex, would not be expected immediately following rhinoplasty and would require intervention, but the manifestation of increased swallowing frequency is a higher priority due to its association with potential bleeding.

2. What is the first intervention for a patient in shock?

• A. Administer fluids
• B. Monitor blood pressure
• C. Provide oxygen
• D. Call for assistance

Correct answer: A

Rationale: The correct answer is to administer fluids. In a patient experiencing shock, the priority is to address inadequate perfusion by restoring circulating blood volume. Administering fluids helps improve perfusion and oxygen delivery to vital organs. Monitoring blood pressure, providing oxygen, and calling for assistance are important steps but administering fluids is the initial and most critical intervention in the management of shock.

3. Which instruction should be emphasized for a client with diabetes being discharged?

• A. Check blood sugar once daily
• B. Take insulin before meals as prescribed
• C. Monitor glucose levels weekly
• D. Eat carbohydrate-rich meals to maintain glucose levels

Correct answer: B

Rationale: The correct answer is to 'Take insulin before meals as prescribed' because it is crucial for managing blood glucose levels effectively in clients with diabetes. Insulin helps the body utilize glucose from the food consumed, preventing high blood sugar levels. Checking blood sugar once daily (Choice A) may not be sufficient for proper management, as blood sugar levels can fluctuate throughout the day. Monitoring glucose levels weekly (Choice C) is too infrequent and may lead to missed opportunities for timely intervention. Eating carbohydrate-rich meals to maintain glucose levels (Choice D) is not appropriate advice, as it can cause rapid spikes in blood sugar levels, especially without the proper insulin dosage.

4. How should a healthcare provider manage care for a patient with a wound infection?

• A. Administer prescribed antibiotics
• B. Clean the wound with saline
• C. Apply a sterile dressing
• D. Monitor for signs of sepsis

Correct answer: A

Rationale: When managing care for a patient with a wound infection, administering prescribed antibiotics is crucial. Antibiotics are necessary to treat the infection and prevent it from worsening. While cleaning the wound with saline and applying a sterile dressing are important components of wound care, the primary treatment for a wound infection is antibiotics. Monitoring for signs of sepsis is also essential, but administering antibiotics promptly is the most critical step in managing a wound infection.

5. A client diagnosed with hypertension requires lifestyle changes. What change should the nurse emphasize?

• A. Increase intake of high-fat foods
• B. Reduce sodium intake
• C. Reduce intake of dairy products
• D. Increase intake of high-protein foods

Correct answer: B

Rationale: Reducing sodium intake is crucial for managing hypertension as excess sodium can lead to increased blood pressure. High-fat foods (Choice A) are not recommended as they can contribute to heart issues. While dairy products (Choice C) should be consumed in moderation, they are not specifically targeted in hypertension management. High-protein foods (Choice D) are not the priority; rather, reducing sodium intake takes precedence due to its direct impact on blood pressure levels.

Similar Questions