Nursing Elites

1. A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to measure the client's vitals every 15 minutes and call him back in 1 hour. From a legal perspective, which of the following actions should the nurse take next?

• A. Notify the nursing manager.
• B. Document the client's condition and communication with the surgeon.
• C. Administer additional fluids as per standard procedure.
• D. Call the surgeon back immediately to ensure timely intervention.

Correct answer: B

Rationale: In this scenario, the nurse should choose option B, which is to document the client's condition and communication with the surgeon. By documenting the client's condition and the communication with the surgeon, the nurse ensures legal protection and maintains continuity of care. This documentation serves as evidence of the actions taken, communication exchanged, and the rationale behind decisions made. Option A, notifying the nursing manager, may not be necessary at this stage unless there are specific institutional protocols requiring it. Administering additional fluids without further clarification may not be appropriate and could worsen the client's condition if not indicated. Calling the surgeon back immediately (option D) may disrupt the agreed-upon plan of action and fail to follow the surgeon's instructions of reassessment after an hour.

2. A client reports increased pain following physical therapy. Which of the following questions should the nurse ask to assess the quality of the pain?

• A. Is the pain sharp or dull?
• B. Does the pain feel like burning or aching?
• C. Is the pain constant or intermittent?
• D. Does the pain feel like throbbing or stabbing?

Correct answer: A

Rationale: When assessing pain quality, asking if the pain is sharp or dull helps determine the nature of the pain. Sharp pain is often associated with acute conditions, while dull pain may indicate a chronic issue. Choices B, C, and D are incorrect as they do not directly address the quality of the pain in terms of sharpness or dullness.

3. While caring for a client who is postoperative and has refused to use an incentive spirometer following major abdominal surgery, what is the nurse's priority action?

• A. Request that a respiratory therapist discuss the technique for using the incentive spirometer
• B. Determine the reasons why the client is refusing to use the incentive spirometer
• C. Document the client's refusal to participate in health restorative activities
• D. Administer a pain medication to the client

Correct answer: B

Rationale: The nurse's priority is to determine the reasons why the client is refusing to use the incentive spirometer. By understanding the client's concerns or barriers, the nurse can address them appropriately. Requesting a respiratory therapist (Choice A) may be necessary later but is not the priority. Documenting the refusal (Choice C) is important but does not address the immediate need to assess and intervene. Administering pain medication (Choice D) without addressing the root cause of refusal is not appropriate and may mask the issue rather than resolve it.

4. A nurse reviews an immobilized patient's laboratory results and discovers hypercalcemia. Which condition will the nurse monitor for most closely in this patient?

• A. Hypostatic pneumonia
• B. Renal stones
• C. Pressure ulcers
• D. Thrombus formation

Correct answer: B

Rationale: The correct answer is B: Renal stones. Renal calculi are calcium stones that can form in the renal pelvis or pass through the ureters. Immobilized patients, who have hypercalcemia, are at increased risk for developing renal stones. Monitoring for signs and symptoms of renal stones is crucial in this patient population. Choices A, C, and D are incorrect because although they are potential complications in immobilized patients, they are not directly associated with hypercalcemia and do not match the scenario described in the question.

5. When ambulating a frail, older adult client, the nurse should:

• A. Use the transfer belt if the client is unsteady
• B. Walk beside the client without support
• C. Encourage the client to use a walker
• D. Hold the client's arm for support

Correct answer: A

Rationale: Using a transfer belt if the client is unsteady is essential to provide added safety and support during ambulation. This device helps the nurse assist the client in maintaining balance and prevents falls. Walking beside the client without support (choice B) may not offer enough assistance for a frail, older adult who is unsteady. Encouraging the client to use a walker (choice C) could be helpful in some cases, but if the client is unsteady during ambulation, additional support like a transfer belt is more appropriate. Holding the client's arm for support (choice D) may not provide enough stability and safety compared to using a transfer belt.

Similar Questions