Nursing Elites

1. A nurse is caring for a client who is postoperative following an abdominal surgery. Which of the following assessments should the nurse prioritize?

• A. Assess the client's pain level.
• B. Monitor the client's respiratory rate.
• C. Measure the client's blood pressure.
• D. Check the client's bowel sounds.

Correct answer: B

Rationale: The correct answer is to monitor the client's respiratory rate. This assessment is crucial in the postoperative period to detect any respiratory complications such as hypoxia or respiratory distress. Assessing pain level (Choice A) is important but may not be the top priority as respiratory status takes precedence. Measuring blood pressure (Choice C) is also important but not as critical immediately postoperatively as monitoring respiratory function. Checking bowel sounds (Choice D) is relevant for assessing gastrointestinal function but is typically not the top priority in the immediate postoperative phase.

2. How should a healthcare provider respond to a patient with a history of hypertension who is non-compliant with medication?

• A. Encourage compliance through education
• B. Contact the healthcare provider
• C. Document the refusal
• D. Explore alternative treatment options

Correct answer: A

Rationale: Encouraging compliance through education is crucial in helping patients understand the importance of consistent medication use. By providing education, the patient can make informed decisions about their health and better manage their condition. Contacting the healthcare provider (choice B) may be necessary in some cases, but the initial approach should focus on patient education. Documenting the refusal (choice C) is important for legal and medical records but does not address the root cause of non-compliance. Exploring alternative treatment options (choice D) should come after efforts to educate and encourage compliance with the current medication regimen.

3. A nurse is caring for a client who is 12 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Serosanguineous drainage on the surgical dressing.
• B. Respiratory rate of 16/min.
• C. Heart rate of 90/min.
• D. WBC count of 15,000/mm3.

Correct answer: D

Rationale: A WBC count of 15,000/mm3 is elevated, which may indicate infection, a common concern postoperatively. An elevated WBC count suggests the body is fighting an infection, and prompt reporting to the provider is essential for further evaluation and treatment. Serosanguineous drainage on the surgical dressing is expected in the immediate postoperative period, respiratory rate of 16/min is within the normal range, and a heart rate of 90/min is also within an acceptable range postoperatively. Therefore, these findings do not raise immediate concerns that necessitate reporting to the provider.

4. A nurse is planning care for a client who has a stage 3 pressure injury. Which of the following interventions should the nurse include in the plan of care?

• A. Cleanse the wound with povidone-iodine solution daily.
• B. Irrigate the wound with hydrogen peroxide.
• C. Reposition the client every 4 hours.
• D. Use a moisture barrier ointment.

Correct answer: D

Rationale: The correct answer is to use a moisture barrier ointment. This intervention helps protect the skin and promote healing in clients with stage 3 pressure injuries. Cleansing the wound with povidone-iodine solution daily (Choice A) can be too harsh and may delay healing by damaging the surrounding skin. Irrigating the wound with hydrogen peroxide (Choice B) is not recommended as it can be cytotoxic to healing tissue. While repositioning the client every 4 hours (Choice C) is an essential intervention in preventing pressure injuries, it is not directly related to the care of an existing stage 3 pressure injury.

5. A client with Raynaud's disease is being cared for by a nurse. What intervention should the nurse implement?

• A. Maintain a warm temperature in the client's room.
• B. Administer epinephrine for acute episodes.
• C. Provide information about stress management.
• D. Give glucocorticoid steroid twice a day.

Correct answer: C

Rationale: The correct intervention for a client with Raynaud's disease is to provide information about stress management. Stress can trigger Raynaud's episodes, so managing stress can help reduce the frequency and severity of the condition. Maintaining a warm temperature in the client's room (Choice A) is important to prevent vasoconstriction and worsening of symptoms. Administering epinephrine (Choice B) is not a standard treatment for Raynaud's disease. Giving glucocorticoid steroids (Choice D) is not the primary treatment for Raynaud's disease and is not typically prescribed for this condition.

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