Nursing Elites

1. A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take to prevent atelectasis?

• A. Encourage deep breathing exercises
• B. Encourage the client to cough every 2 hours
• C. Administer an incentive spirometer
• D. Assist the client to ambulate in the hallway

Correct answer: C

Rationale: The correct answer is C: Administer an incentive spirometer. Using an incentive spirometer helps prevent atelectasis by encouraging lung expansion after surgery. Encouraging deep breathing exercises (choice A) is beneficial but may not be as effective as an incentive spirometer. Encouraging the client to cough (choice B) helps with airway clearance but does not directly prevent atelectasis. Assisting the client to ambulate (choice D) is important for preventing complications such as deep vein thrombosis, but it is not the most effective intervention for preventing atelectasis.

2. What is the most important intervention when managing a client with delirium?

• A. Administer a sedative to reduce agitation
• B. Identify any reversible causes of delirium
• C. Increase environmental stimulation
• D. Limit noise and provide a calm environment

Correct answer: B

Rationale: The correct answer is B: 'Identify any reversible causes of delirium.' When managing a client with delirium, it is crucial to first identify and address any reversible factors contributing to the delirium. Administering sedatives (Choice A) may worsen delirium and is not the primary intervention. Increasing environmental stimulation (Choice C) can exacerbate symptoms. Limiting noise and providing a calm environment (Choice D) are beneficial but not as crucial as identifying reversible causes.

3. What are the common causes of postoperative pain and how should it be managed?

• A. Surgical incision and muscle tension
• B. Nerve damage and wound complications
• C. Hypotension and respiratory issues
• D. Infection at the incision site

Correct answer: A

Rationale: Postoperative pain is commonly caused by the surgical incision and muscle tension. The correct answer is A. Surgical incisions cause tissue damage, triggering pain responses. Muscle tension can result from factors like positioning during surgery or guarding due to pain. Managing postoperative pain caused by surgical incisions and muscle tension involves the use of analgesics to alleviate discomfort. Choices B, C, and D are incorrect. Nerve damage and wound complications may also cause pain but are not as common as surgical incisions and muscle tension. Hypotension and respiratory issues are not direct causes of postoperative pain. Infection at the incision site can lead to pain, but it is a specific complication rather than a common cause of postoperative pain.

4. A home health nurse is preparing for an initial visit with an older adult client who lives alone. Which of the following actions should the nurse take first?

• A. Educate the client about their current medical diagnosis.
• B. Refer the client to a meal delivery program.
• C. Identify environmental hazards in the home.
• D. Arrange transportation for the client to follow-up appointments.

Correct answer: C

Rationale: Identifying environmental hazards in the client's home is the priority during the initial visit with an older adult living alone. This action is crucial to prevent accidents, falls, and ensure the client's safety. While educating the client about their medical diagnosis, referring them to a meal delivery program, and arranging transportation for follow-up appointments are essential, addressing environmental hazards takes precedence as it directly impacts the client's immediate safety and well-being.

5. A client has developed phlebitis at the IV site. What is the most appropriate next step?

• A. Apply a warm compress over the IV site
• B. Notify the provider and discontinue the IV infusion
• C. Increase the IV flow rate to clear the blockage
• D. Elevate the extremity and apply an ice pack

Correct answer: B

Rationale: Phlebitis, inflammation of a vein, is a complication that requires prompt action. The most appropriate next step is to discontinue the IV infusion and notify the healthcare provider. Applying a warm compress, increasing the IV flow rate, or applying an ice pack are not appropriate interventions for phlebitis. Warm compresses may worsen inflammation, increasing the IV flow rate could exacerbate the condition, and ice packs are not recommended for phlebitis.

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