Nursing Elites

1. A nurse is providing discharge teaching to a client who has had a stroke. Which of the following instructions should the nurse include?

• A. Avoid taking anticoagulant medication.
• B. Limit fluid intake to 1,000 mL per day.
• C. Avoid isometric exercises during recovery.
• D. Perform range-of-motion exercises daily.

Correct answer: D

Rationale: The correct answer is D: Perform range-of-motion exercises daily. After a stroke, performing range-of-motion exercises can help prevent complications such as joint stiffness and contractures. Options A, B, and C are incorrect. Anticoagulant medications are often prescribed to prevent blood clots after a stroke, fluid intake should be adequate unless indicated otherwise, and isometric exercises can be beneficial during recovery.

2. What is the first action for a healthcare provider when a patient experiences a fall?

• A. Assess the patient for injuries
• B. Call for help
• C. Document the fall
• D. Notify the healthcare provider

Correct answer: A

Rationale: The correct answer is to 'Assess the patient for injuries' when a patient experiences a fall. This is crucial to promptly identify any injuries and provide appropriate care. Calling for help may be necessary, but assessing the patient's condition takes precedence to ensure immediate attention to any injuries. Documenting the fall and notifying the healthcare provider would follow after the initial assessment and necessary actions have been taken.

3. A nurse is assessing a client who has acute pancreatitis. Which of the following findings should the nurse expect?

• A. Left upper quadrant pain.
• B. Periumbilical pain.
• C. Rebound tenderness.
• D. Flank pain.

Correct answer: A

Rationale: Corrected Rationale: The correct answer is A, left upper quadrant pain. In acute pancreatitis, inflammation of the pancreas commonly causes pain in the left upper quadrant of the abdomen. This pain can be severe and radiate to the back. Periumbilical pain (choice B) is more indicative of acute appendicitis. Rebound tenderness (choice C) is associated with peritoneal inflammation, not specifically pancreatitis. Flank pain (choice D) is more characteristic of conditions involving the kidneys or ureters, such as renal colic.

4. A nurse is caring for a client who is in the orientation phase of the therapeutic relationship. Which statement should the nurse make during this phase?

• A. Let's talk about how you can change your response to stress.
• B. We should establish our roles in the initial session.
• C. Let me show you simple relaxation exercises to manage stress.
• D. We should discuss resources to implement in your daily life.

Correct answer: B

Rationale: During the orientation phase of the therapeutic relationship, it is crucial to establish roles. This helps both the client and the nurse understand their responsibilities, boundaries, and expectations within the therapeutic process. Choice A is more focused on the working phase where strategies and interventions are discussed. Choice C is more suitable for the working phase where specific techniques are usually introduced. Choice D is also more relevant to the working phase as it involves discussing practical resources for implementation in daily life.

5. A nurse is caring for a client who has deep vein thrombosis of the left lower extremity. Which of the following actions should the nurse take?

• A. Position the client with the affected extremity higher than the heart
• B. Administration of acetaminophen
• C. Massage the affected extremity every 4 hours
• D. Withhold heparin IV infusion

Correct answer: D

Rationale: The correct action for the nurse to take when caring for a client with deep vein thrombosis is to withhold heparin IV infusion. Administering heparin is crucial in managing deep vein thrombosis by preventing further clot formation. Positioning the affected extremity higher than the heart (Choice A) promotes venous return and reduces swelling. Acetaminophen (Choice B) can be given for pain relief. Massaging the affected extremity (Choice C) is contraindicated as it can dislodge a clot, leading to serious complications.

Similar Questions