Nursing Elites

1. A client is on bed rest. Which of the following interventions should the nurse plan to implement?

• A. Encourage the client to perform antiembolic exercises every 2 hours.
• B. Instruct the client to cough and deep breathe every 4 hours.
• C. Restrict the client’s fluid intake.
• D. Reposition the client every 4 hours.

Correct answer: A

Rationale: To prevent complications associated with prolonged bed rest, encouraging the client to perform antiembolic exercises every 2 hours is essential. These exercises help promote circulation and prevent blood clots. Instructing the client to cough and deep breathe every 4 hours is beneficial for respiratory function, but it is not as critical as antiembolic exercises. Repositioning the client every 4 hours helps prevent pressure ulcers and maintain skin integrity. Restricting fluid intake is not recommended, as hydration is important for overall health and well-being, especially for clients on bed rest.

2. The nurse is providing discharge teaching to a client who has been prescribed warfarin (Coumadin). Which statement by the client indicates a need for further teaching?

• A. I will avoid eating foods high in vitamin K.
• B. I will take my medication at the same time every day.
• C. I will use a soft toothbrush to prevent gum bleeding.
• D. I can take aspirin if I have a headache.

Correct answer: D

Rationale: The correct answer is D: 'I can take aspirin if I have a headache.' This statement indicates a need for further teaching because aspirin can increase the risk of bleeding in clients taking warfarin. Clients on warfarin therapy should avoid taking aspirin or other medications that increase the risk of bleeding. Choices A, B, and C are correct statements that show understanding of warfarin therapy, such as the importance of avoiding foods high in vitamin K, taking medication consistently, and using a soft toothbrush to prevent gum bleeding.

3. The healthcare professional is preparing to administer a medication through a nasogastric (NG) tube. Which action should the healthcare professional take to ensure proper administration?

• A. Flush the tube with 30 ml of water before and after medication administration.
• B. Administer the medication with food to prevent nausea.
• C. Verify tube placement by aspirating stomach contents.
• D. Dilute the medication with normal saline before administration.

Correct answer: A

Rationale: Flushing the NG tube with water before and after medication administration is essential to ensure the tube is patent and prevent clogging. This action helps in clearing the tube and ensures that the medication is delivered properly. Administering medication with food (Choice B) may not be appropriate for all medications and can interfere with their absorption. Verifying tube placement by aspirating stomach contents (Choice C) is important but does not directly relate to ensuring proper medication administration. Diluting the medication with normal saline (Choice D) is not a standard practice for administering medications through an NG tube.

4. An older adult client just diagnosed with colon cancer asks the nurse what the primary care provider is going to do. The provider will be making rounds within the hour. Which of the following nursing actions is appropriate?

• A. Help the client write down the questions to ask the provider, so that the client doesn’t forget
• B. Reassure the client that everything will be explained
• C. Explain the procedure in detail yourself
• D. Direct the client to search for information online

Correct answer: A

Rationale: Assisting the client in preparing questions is the most appropriate action as it helps ensure that all concerns are addressed during the provider's visit. By helping the client write down questions, the nurse empowers the client to actively participate in their care and communicate effectively with the provider. Reassuring the client, while well-intentioned, may not address the specific questions or fears the client has. Explaining the procedure in detail may not be what the client is seeking at this moment, as their primary concern is about the provider's actions. Directing the client to search for information online is not recommended as it may lead to confusion or misinformation, and the information may not be tailored to the client's specific situation.

5. What action should the LPN/LVN take to prevent postoperative complications in a client who has undergone abdominal surgery?

• A. Encourage the client to use an incentive spirometer regularly.
• B. Assist the client in ambulating as soon as possible.
• C. Position the client in high Fowler's position.
• D. Encourage the client to cough and deep breathe regularly.

Correct answer: A

Rationale: Encouraging the client to use an incentive spirometer regularly is crucial in preventing postoperative complications after abdominal surgery. This action helps prevent atelectasis by promoting lung expansion and improving air exchange in the lungs, reducing the risk of respiratory complications. Assisting the client in ambulating early is important for preventing issues like deep vein thrombosis but may not directly address respiratory concerns postoperatively. Positioning the client in high Fowler's position can help with respiratory distress but is not as specific to preventing postoperative respiratory complications as using an incentive spirometer. While encouraging the client to cough and deep breathe is generally beneficial for lung expansion, using an incentive spirometer is more effective and targeted in preventing atelectasis after abdominal surgery.

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