Nursing Elites

1. A client who has undergone vein ligation and stripping to treat varicose veins should be instructed to do which of the following activities during discharge teaching?

• A. Remain sedentary for 2-3 days
• B. Walk for 1-2 hours each day
• C. Wear compression stockings only at night
• D. Elevate legs while sitting

Correct answer: B

Rationale: The correct answer is B: 'Walk for 1-2 hours each day.' After vein ligation and stripping, walking helps promote circulation and aids in the recovery process. Option A is incorrect as remaining sedentary for 2-3 days can lead to decreased circulation and potentially increase the risk of complications. Option C is incorrect because compression stockings should typically be worn during the day to support circulation. Option D is incorrect as elevating the legs while sitting is beneficial, but walking is more effective in promoting circulation and recovery in this case.

2. Which of the following is the best intervention for managing dehydration?

• A. Administer antiemetics to prevent nausea
• B. Monitor fluid and electrolyte levels
• C. Encourage the client to drink more fluids
• D. Administer intravenous fluids

Correct answer: B

Rationale: The best intervention for managing dehydration is to monitor fluid and electrolyte levels. This approach allows healthcare providers to assess the severity of dehydration, determine appropriate fluid replacement therapy, and prevent complications. Administering antiemetics (Choice A) may help with nausea but does not address the underlying issue of dehydration. Encouraging the client to drink more fluids (Choice C) may be appropriate for mild dehydration but can be inadequate for moderate to severe cases. Administering intravenous fluids (Choice D) is crucial for severe dehydration or cases where oral rehydration is ineffective, but monitoring fluid and electrolyte levels should precede this intervention.

3. When caring for a client diagnosed with delirium, which condition is most important for the nurse to investigate?

• A. Cancer of any kind
• B. Impaired hearing
• C. Prescription drug intoxication
• D. Heart failure

Correct answer: C

Rationale: When caring for a client diagnosed with delirium, the most important condition for the nurse to investigate is prescription drug intoxication. Delirium can be caused by various factors, and prescription drug intoxication is a common reversible cause. Investigating this factor first is crucial to identify and address the underlying cause promptly. Choices A, B, and D are less likely to be directly associated with delirium compared to prescription drug intoxication. While cancer, impaired hearing, and heart failure can have their complications and effects, they are not typically the primary causes of delirium in a client.

4. A nurse is observing an assistive personnel (AP) caring for a client. For which of the following actions by the AP should the nurse intervene?

• A. Providing care in the hallway
• B. Reporting client information in the hallway
• C. Helping another client use the restroom
• D. Feeding the client too quickly

Correct answer: B

Rationale: The correct answer is B because reporting client information in the hallway violates privacy regulations, compromising patient confidentiality. Providing care in the hallway (choice A) may not be ideal but is not a direct violation. Helping another client use the restroom (choice C) shows the AP's willingness to assist but is not a concern unless it compromises the current client's safety. Feeding the client too quickly (choice D) is a potential concern for aspiration but may not require immediate intervention as addressing hydration and swallowing strategies can help prevent complications.

5. A client is given morphine 6 mg IV push for postoperative pain. Following administration of this drug, the nurse observes the following: pulse 68, respirations 8, BP 100/68, client sleeping quietly. Which of the following nursing actions is MOST appropriate?

• A. Allow the client to sleep undisturbed
• B. Administer oxygen via facemask or nasal prongs
• C. Administer naloxone (Narcan)
• D. Place epinephrine 1:1,000 at the bedside

Correct answer: C

Rationale: The correct answer is to administer naloxone (Narcan). The client's vital signs indicate opioid-induced respiratory depression, which is a potential side effect of morphine. Naloxone is used to reverse the effects of opioids, particularly to restore normal respiratory function. Administering oxygen alone (Choice B) may not address the underlying cause of respiratory depression. Allowing the client to sleep undisturbed (Choice A) is inappropriate when signs of respiratory depression are present. Epinephrine (Choice D) is not indicated in this situation and is not used to reverse opioid effects.

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