Nursing Elites

1. A client is postoperative following a rhinoplasty, and a nurse is contributing to the plan of care. Which of the following interventions should the nurse recommend?

• A. Administer humidified oxygen
• B. Restrict fluids
• C. Instruct the client to avoid the Valsalva maneuver
• D. Apply heat packs to the nose

Correct answer: C

Rationale: Instructing the client to avoid the Valsalva maneuver is crucial after rhinoplasty to reduce strain and the risk of bleeding. Administering humidified oxygen may not be directly related to postoperative care for rhinoplasty. Restricting fluids is not typically necessary unless specifically indicated by the healthcare provider. Applying heat packs to the nose is contraindicated after rhinoplasty as it can increase the risk of bleeding and should be avoided.

2. What is the most important nursing action when administering IV potassium?

• A. Monitor for decreased urine output
• B. Administer via IV push
• C. Administer slowly and dilute in IV fluids
• D. Ensure the client drinks 500 mL of water before administration

Correct answer: C

Rationale: The most important nursing action when administering IV potassium is to administer it slowly and dilute it in IV fluids. This approach helps prevent irritation and hyperkalemia. Monitoring for decreased urine output (Choice A) is important but not as critical as ensuring the safe administration of IV potassium. Administering potassium via IV push (Choice B) is unsafe and can lead to adverse effects. Ensuring the client drinks water before administration (Choice D) is not directly related to the safe administration of IV potassium.

3. A nurse is teaching a client how to administer enoxaparin. Which of the following instructions should the nurse include?

• A. Inject the medication into the muscle of the thigh
• B. Massage the injection site after administration
• C. Pinch the skin before injecting
• D. Administer the medication at the same time each day

Correct answer: C

Rationale: The correct instruction for administering enoxaparin is to pinch the skin before injecting. Pinching the skin helps create a proper fold for subcutaneous injections like enoxaparin, ensuring proper delivery of the medication into the subcutaneous tissue. Choice A is incorrect because enoxaparin should be administered subcutaneously, not into the muscle. Injecting it into the muscle can lead to complications. Choice B is incorrect because massaging the injection site after administration can increase the risk of bleeding or bruising due to the anticoagulant properties of enoxaparin. Choice D is incorrect as it is a general instruction and does not specifically relate to the administration of enoxaparin.

4. What are the signs and symptoms of opioid withdrawal, and how should they be managed?

• A. Nausea, sweating, and increased heart rate; manage with methadone
• B. Pain and restlessness; manage with naloxone
• C. Hallucinations and muscle cramps; manage with clonidine
• D. Severe vomiting and seizures; manage with benzodiazepines

Correct answer: A

Rationale: The signs and symptoms of opioid withdrawal include nausea, sweating, and increased heart rate. Methadone is commonly used to manage opioid withdrawal symptoms by alleviating them. Choice B, managing with naloxone, is incorrect as naloxone is primarily used for opioid overdose reversal, not withdrawal. Choice C, managing with clonidine, is incorrect as clonidine is used to manage some symptoms of withdrawal, such as anxiety, agitation, and hypertension, but not hallucinations. Choice D, managing with benzodiazepines, is incorrect as benzodiazepines are not typically used as first-line treatment for opioid withdrawal; they may be considered in specific cases but are not a standard approach.

5. A nurse is assessing the remote memory of an older adult client who has mild dementia. Which of the following questions should the nurse ask the client?

• A. Can you tell me who visited you today?
• B. What high school did you graduate from?
• C. Can you list your current medications?
• D. What did you have for breakfast yesterday?

Correct answer: B

Rationale: The correct answer is B: 'What high school did you graduate from?' Remote memory involves recalling past events, such as educational history, making option B the most appropriate question to assess this aspect of memory in an older adult with mild dementia. Option A pertains to recent memory. Option C focuses on short-term memory. Option D addresses recent memory as well.

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