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 caring for a client who has peptic ulcer disease (PUD) and is prescribed sucralfate. Which of the following instructions should the nurse include in the teaching?

• A. Take sucralfate with an antacid.
• B. Take sucralfate 1 hour before meals.
• C. Take sucralfate with food.
• D. Take sucralfate at bedtime only.

Correct answer: B

Rationale: The correct answer is B. Sucralfate should be taken on an empty stomach, 1 hour before meals. This timing allows sucralfate to form a protective barrier over the ulcer, enhancing healing. Choice A is incorrect because sucralfate should not be taken with an antacid. Choice C is incorrect because sucralfate should not be taken with food. Choice D is incorrect because sucralfate should not be taken at bedtime only; it is best absorbed on an empty stomach.

3. A client with a new prescription for an albuterol metered-dose inhaler is being taught by a nurse. Which of the following instructions should the nurse include in the teaching?

• A. Inhale quickly when using the inhaler.
• B. Hold your breath for 10 seconds after inhaling the medication.
• C. Take a second puff of the inhaler immediately after the first.
• D. Exhale fully after using the inhaler.

Correct answer: B

Rationale: The correct instruction is to hold your breath for 10 seconds after inhaling the medication. This allows the medication to settle in the lungs and maximize its effectiveness. Choice A is incorrect as inhaling quickly may lead to improper medication delivery. Choice C is wrong because taking a second puff immediately after the first without waiting for the prescribed interval may cause an overdose. Choice D is also incorrect as exhaling fully after using the inhaler may result in the medication being exhaled rather than absorbed by the lungs.

4. A nurse is planning care for a group of postoperative clients. Which of the following interventions should the nurse identify as the priority?

• A. Administer IV pain medication to a client who reports pain as a 6 on a scale of 0 to 10
• B. Administer oxygen to a client who has an oxygen saturation of 91%
• C. Instruct a client who is 1 hr postoperative about coughing and deep breathing exercises
• D. Initiate an infusion of 0.9% sodium chloride for a client who has just had abdominal surgery

Correct answer: B

Rationale: When using the ABC approach to client care, the nurse should identify that the priority intervention is administering oxygen. In this scenario, the client's oxygen saturation is only 91%, which is below the normal range of 95% and above. Oxygen is essential for adequate tissue perfusion and oxygenation of vital organs. Administering oxygen takes precedence over other interventions to ensure the client's physiological needs are met first. Choice A can be addressed after ensuring adequate oxygenation. Choice C is important for preventing postoperative complications but is not as urgent as addressing oxygen saturation. Choice D is a common postoperative intervention, but in this case, ensuring adequate oxygenation is the priority over IV fluid administration.

5. While caring for a newborn under phototherapy lights, what is an appropriate nursing action?

• A. Ensure an eye shield is covering the eyes
• B. Apply lotion to the exposed skin
• C. Offer glucose water between feedings
• D. Discontinue breastfeeding during treatment

Correct answer: A

Rationale: The correct answer is to ensure an eye shield is covering the eyes. This action is essential to protect the newborn's eyes from the bright light used in phototherapy. Applying lotion to the exposed skin (Choice B) is not necessary and may interfere with the treatment. Offering glucose water between feedings (Choice C) is not indicated and may not be appropriate for a newborn undergoing phototherapy. Discontinuing breastfeeding during treatment (Choice D) is not recommended as breastfeeding should be continued unless contraindicated.

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