Nursing Elites

1. A client postoperative expresses pain during dressing changes. What should the nurse prioritize?

• A. Administer pain medication 45 minutes before changing the client’s dressing.
• B. Change the dressing less frequently.
• C. Apply a topical anesthetic before removing the dressing.
• D. Use a non-adherent dressing to reduce pain.

Correct answer: A

Rationale: Administering pain medication before changing the dressing is the priority action as it will help alleviate the client's pain and improve comfort. Choice B, changing the dressing less frequently, may hinder proper wound care and healing. Applying a topical anesthetic (choice C) might offer some relief but systemic pain medication is more effective. Using a non-adherent dressing (choice D) can reduce pain during dressing changes, but addressing immediate pain with medication is the most appropriate intervention in this case.

2. A healthcare professional is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the healthcare professional identify as an indication that the treatment was successful?

• A. Decrease in heart rate
• B. Fluid volume deficit causes tachycardia
• C. Decrease in blood pressure
• D. Increase in respiratory rate

Correct answer: A

Rationale: A decrease in heart rate can indicate that the fluid volume deficit is improving. In cases of fluid volume deficit, the body compensates by increasing the heart rate to maintain adequate perfusion. Therefore, a decrease in heart rate after fluid resuscitation suggests that the body's perfusion status is improving. Choices B, C, and D are incorrect because fluid volume deficit typically causes tachycardia, not a decrease in heart rate, and would not result in a decrease in blood pressure or an increase in respiratory rate as primary signs of improvement.

3. What intervention can help prevent atelectasis and pneumonia in a client with amyotrophic lateral sclerosis?

• A. Active and passive range of motion exercises twice a day
• B. Every 4 hours incentive spirometer
• C. Chest physiotherapy twice a day
• D. Repositioning every 2 hours around the clock

Correct answer: C

Rationale: Chest physiotherapy is essential for clients with amyotrophic lateral sclerosis (ALS) to prevent atelectasis and pneumonia. Chest physiotherapy aids in clearing secretions, maintaining lung function, and preventing respiratory complications. Active and passive range of motion exercises (Choice A) are important for maintaining joint mobility but are not directly associated with preventing atelectasis and pneumonia in ALS. Incentive spirometer use every 4 hours (Choice B) is beneficial for lung expansion and preventing atelectasis but may not be as effective as chest physiotherapy in managing secretions. Repositioning every 2 hours (Choice D) is crucial for preventing pressure ulcers but is not directly related to preventing atelectasis and pneumonia in ALS.

4. The healthcare provider is monitoring a client in active labor. Which pattern on the fetal heart monitor requires immediate intervention?

• A. Early decelerations
• B. Late decelerations
• C. Accelerations
• D. Moderate variability

Correct answer: B

Rationale: Late decelerations are concerning as they indicate uteroplacental insufficiency, potentially resulting in fetal hypoxia. Immediate intervention is necessary to address the underlying cause and ensure fetal well-being. Early decelerations are typically benign and associated with head compression during contractions. Accelerations are reassuring and indicate fetal well-being. Moderate variability is a normal finding and indicates a healthy autonomic nervous system response. Therefore, late decelerations (Choice B) require immediate attention, while the other patterns are generally considered normal or benign during labor.

5. A nurse is caring for an older adult client who becomes agitated when the nurse requests the client’s dentures be removed prior to surgery. Which of the following responses should the nurse make?

• A. You seem worried. Are you concerned someone may see you without your teeth?
• B. Don't worry, it’s just for the surgery.
• C. You need to follow the instructions.
• D. The dentures need to be removed for a reason.

Correct answer: D

Rationale: The correct response is to provide a clear rationale for the request, as stated in option D. By explaining the purpose behind removing the dentures, the nurse helps the client understand the necessity, which can reduce agitation and promote cooperation. Option A demonstrates empathy by addressing the client's potential concern about being seen without dentures but lacks a direct explanation. Option B dismisses the client's feelings with a casual statement that may not address the underlying issue. Option C is authoritarian and lacks empathy, potentially escalating the client's agitation.

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