Nursing Elites

1. A client who has undergone a cesarean birth is receiving discharge instructions from a nurse. Which of the following should the nurse include in the instructions?

• A. Limit stair climbing for the first few weeks
• B. Avoid lifting anything heavier than the newborn
• C. Use a pillow to support the abdomen when coughing or sneezing
• D. All of the above

Correct answer: D

Rationale: After a cesarean birth, it is important for the client to follow specific instructions for optimal recovery. Limiting stair climbing reduces strain on the incision site, aiding in healing (Choice A). Avoiding lifting anything heavier than the newborn prevents stress on the incision, promoting recovery (Choice B). Using a pillow to support the abdomen during coughing or sneezing helps reduce discomfort and protect the incision, preventing sudden movements or strain (Choice C). Therefore, all the options provided are crucial post-cesarean birth instructions to ensure proper healing and recovery. Choices A, B, and C are all essential components of post-cesarean care, making Option D the correct answer.

2. A nurse is providing discharge teaching for a client who has COPD about nutrition. Which of the following instructions should the nurse include?

• A. Eat three large meals daily
• B. Consume high-calorie, high-protein foods
• C. Limit caffeinated drinks to two per day
• D. Drink fluids between meals

Correct answer: B

Rationale: The correct answer is B: 'Consume high-calorie, high-protein foods.' Clients with COPD often have increased energy needs due to the work of breathing. Consuming high-calorie, high-protein foods can help provide the necessary energy and prevent weight loss. Choice A is incorrect because eating three large meals daily may lead to increased shortness of breath due to a full stomach. Choice C is incorrect because limiting caffeinated drinks is important, but the recommendation should focus on reducing intake, not specifying a number. Choice D is incorrect because drinking fluids during mealtime can lead to early satiety, making it difficult for the client to consume enough calories.

3. A nurse is providing discharge teaching for a client newly prescribed methadone. Which statement indicates a need for further teaching?

• A. I understand methadone slows my breathing.
• B. I understand methadone may cause me to have trouble sleeping.
• C. I will avoid alcohol while taking this medication.
• D. I’ll change positions slowly to prevent dizziness.

Correct answer: B

Rationale: The correct answer is B. Trouble sleeping is not a typical side effect of methadone; the nurse should clarify this misunderstanding. Choices A, C, and D are all correct statements regarding methadone. Methadone can indeed slow breathing, so it is important for the client to be aware of this effect. Avoiding alcohol while taking methadone is crucial due to the increased risk of central nervous system depression when alcohol is combined with methadone. Additionally, changing positions slowly can help prevent dizziness, which can be a side effect of methadone.

4. A nurse is providing discharge instructions for a client after surgery. Which of the following should be included?

• A. Resume normal activities immediately
• B. Monitor for signs of infection
• C. Avoid all physical activity for 1 month
• D. Take pain medications only as needed

Correct answer: B

Rationale: The correct answer is B: 'Monitor for signs of infection.' After surgery, it is essential for clients to watch for signs of infection, such as increased redness, swelling, or drainage at the incision site. Choice A is incorrect because resuming normal activities immediately after surgery can be harmful. Choice C is incorrect as complete avoidance of physical activity for a month is typically not necessary and can lead to complications like blood clots. Choice D is incorrect as taking pain medications only as needed may not provide adequate pain management post-surgery.

5. A nurse is assisting with mass casualty triage following an explosion at a local factory. Which of the following clients should the nurse identify as the priority?

• A. A client who has massive head trauma
• B. A client who has full-thickness burns to the face and trunk
• C. A client with indications of hypovolemic shock
• D. A client with an open fracture of the lower extremity

Correct answer: C

Rationale: In a mass casualty situation, the nurse should prioritize the client with indications of hypovolemic shock. Hypovolemic shock is an immediate life-threatening condition resulting from severe blood loss, which can lead to organ failure and death. Prompt identification and treatment of hypovolemic shock are crucial to prevent further deterioration. While clients with massive head trauma, full-thickness burns, and open fractures require urgent care, hypovolemic shock takes precedence due to its rapid progression to a critical state.

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