Nursing Elites

1. A nurse is caring for a client who is postpartum and reports perineal pain. Which intervention should the nurse implement?

• A. Administer analgesics as prescribed.
• B. Apply a warm compress to the perineum.
• C. Encourage the client to ambulate frequently.
• D. Position the client with the head elevated.

Correct answer: A

Rationale: Administering analgesics as prescribed is the appropriate intervention for managing perineal pain in a postpartum client. Analgesics help to alleviate discomfort and promote the client's recovery. Applying a warm compress (choice B) may provide some relief, but it does not address the pain as effectively as analgesics. Encouraging ambulation (choice C) and positioning the client with the head elevated (choice D) are not directly related to addressing perineal pain.

2. A nurse is providing discharge teaching to a client who has had a stroke. Which of the following instructions should the nurse include?

• A. Avoid taking anticoagulant medication.
• B. Limit fluid intake to 1,000 mL per day.
• C. Avoid isometric exercises during recovery.
• D. Perform range-of-motion exercises daily.

Correct answer: D

Rationale: The correct answer is D: Perform range-of-motion exercises daily. After a stroke, performing range-of-motion exercises can help prevent complications such as joint stiffness and contractures. Options A, B, and C are incorrect. Anticoagulant medications are often prescribed to prevent blood clots after a stroke, fluid intake should be adequate unless indicated otherwise, and isometric exercises can be beneficial during recovery.

3. What is the most important assessment for a patient post-op to monitor for complications?

• A. Monitor vital signs
• B. Monitor the surgical site
• C. Check blood glucose levels
• D. Check for abnormal breath sounds

Correct answer: A

Rationale: The correct answer is to monitor vital signs. Post-operative patients need close monitoring of their vital signs to detect early signs of complications such as changes in blood pressure, heart rate, temperature, and respiratory rate. While monitoring the surgical site is also important for signs of infection, assessing vital signs takes precedence as it provides immediate information about the patient's overall condition. Checking blood glucose levels may be essential for specific patients but is not the primary assessment for monitoring post-op complications. Checking for abnormal breath sounds is important but falls secondary to monitoring vital signs as it indicates respiratory issues rather than providing a comprehensive assessment of the patient's condition.

4. A nurse is planning care for a client who practices Orthodox Judaism and is observing the Passover holiday. Which of the following actions should the nurse include in the plan of care?

• A. Provide chicken with cream sauce.
• B. Avoid serving fish with fins and scales.
• C. Provide unleavened bread.
• D. Avoid serving foods containing lamb.

Correct answer: C

Rationale: During the Passover holiday, individuals practicing Orthodox Judaism follow dietary restrictions that include avoiding leavened bread. Providing unleavened bread aligns with these restrictions and ensures the client's observance of the holiday. Choices A, B, and D are incorrect because serving chicken with cream sauce, avoiding fish with fins and scales, and avoiding foods containing lamb are not specific dietary requirements related to observing Passover in Orthodox Judaism.

5. A client is being taught how to perform self-catheterization. Which of the following instructions should the nurse include?

• A. Clean the catheter with alcohol after each use.
• B. Perform self-catheterization while sitting on the toilet.
• C. Use a new catheter each time you perform self-catheterization.
• D. Lubricate the catheter tip with petroleum jelly before insertion.

Correct answer: C

Rationale: The correct answer is C: 'Use a new catheter each time you perform self-catheterization.' It is essential to use a new, sterile catheter each time to prevent infection during the procedure. Choice A is incorrect because cleaning the catheter with alcohol may not be sufficient to prevent infection. Choice B is incorrect because self-catheterization is typically done in a clean, private area, not necessarily on the toilet. Choice D is incorrect because lubricating the catheter tip with petroleum jelly is a common practice but not as crucial as using a new catheter each time to prevent infection.

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