Nursing Elites

1. When caring for an older adult client who becomes agitated when asked to remove dentures before surgery, which of the following responses should the nurse make?

• A. "What worries you about being without your teeth?"
• B. "You need to follow the preoperative instructions and remove your dentures."
• C. "It's important to remove dentures to ensure proper fitting of the mask during anesthesia."
• D. "I will explain why dentures need to be removed before surgery."

Correct answer: A

Rationale: The correct response is to ask the client about their concerns regarding being without their teeth. This approach helps address the client's anxiety and provides insight into the reason for their agitation. Choice B is authoritarian and does not address the client's emotional needs. Choice C focuses on the technical aspect of surgery and does not address the client's emotional state. Choice D implies a one-way communication without addressing the client's feelings or concerns.

2. A client with chronic back pain asks a nurse about receiving acupuncture for relief. Which of the following findings should the nurse identify as a contraindication to receiving this treatment?

• A. Obesity
• B. Hypertension
• C. Migraines
• D. Cellulitis

Correct answer: D

Rationale: The correct answer is D, Cellulitis. Cellulitis is a contraindication for acupuncture due to the risk of infection. Acupuncture involves inserting needles into the skin, and if a person has cellulitis, which is a bacterial skin infection, there is a higher risk of introducing the infection deeper into the body. Obesity (choice A), hypertension (choice B), and migraines (choice C) are not contraindications for receiving acupuncture. These conditions do not pose a direct risk of complications related to acupuncture treatment.

3. While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the LPN/LVN implement?

• A. Acknowledge that she is supporting the arm correctly.
• B. Encourage her to keep the joint covered to maintain warmth.
• C. Reinforce the need to grip directly under the joint for better support.
• D. Instruct her to grip directly over the joint for better motion.

Correct answer: A

Rationale: Acknowledging that the client's wife is supporting the arm correctly is the appropriate nursing action in this scenario. By doing so, the nurse reinforces correct technique and promotes confidence. Choice B is incorrect as the issue is not about maintaining warmth. Choice C is incorrect as gripping directly under the joint is not necessary in this case. Choice D is incorrect as instructing to grip directly over the joint may not provide the best support for passive range-of-motion exercises.

4. The healthcare provider is planning care for a 3-month-old infant immediately postoperative following placement of a ventriculoperitoneal shunt for hydrocephalus. The healthcare provider needs to

• A. Assess for abdominal distention
• B. Maintain the infant in an upright position
• C. Begin feeding formula when the infant is alert
• D. Pump the shunt to assess for proper function

Correct answer: A

Rationale: Assessing for abdominal distention is crucial in this situation as it can indicate a complication with the shunt or fluid accumulation. Abdominal distention may suggest an issue with the shunt placement, such as obstruction or overdrainage, which requires immediate intervention. Maintaining the infant in an upright position (Choice B) is not the priority immediately postoperatively following a ventriculoperitoneal shunt placement. Beginning formula feedings when the infant is alert (Choice C) may be appropriate but is not the priority over assessing for abdominal distention. Pumping the shunt to assess for proper function (Choice D) is not a recommended nursing intervention postoperatively and should be done by a qualified healthcare provider.

5. A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge?

• A. Asks relevant questions regarding the dressing change.
• B. States he will be able to complete the wound care regimen.
• C. Demonstrates the wound care procedure correctly.
• D. Has all the necessary supplies for wound care.

Correct answer: C

Rationale: The correct answer is C. Demonstrating the wound care procedure correctly indicates the client's readiness to independently manage wound care. This action shows practical understanding and application of the necessary skills. Choice A, asking relevant questions, is important but does not directly demonstrate the ability to perform the procedure. Choice B, stating the ability to complete the regimen, is a good intention but does not confirm practical competence. Choice D, having necessary supplies, is essential but does not ensure the client's ability to execute proper wound care.

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