Nursing Elites

1. A nurse is reviewing the medical record of a client with dementia who frequently becomes agitated. What should the nurse prioritize?

• A. Investigate the client's fluid and electrolyte balance
• B. Investigate the client's recent medication changes
• C. Investigate recent changes in cognitive functioning
• D. Investigate the client's psychosocial environment

Correct answer: B

Rationale: The correct answer is to investigate the client's recent medication changes. In a client with dementia who frequently becomes agitated, medication changes can often be a significant factor contributing to their behavior. Checking recent medication changes can help identify if any specific medication is causing or exacerbating the agitation. Choice A about fluid and electrolyte balance is less likely to be the priority unless there are specific indications in the medical record. Choice C, investigating recent changes in cognitive functioning, may be important but addressing the agitation first is a more immediate concern. Choice D, investigating the client's psychosocial environment, is also important but may not directly address the immediate cause of the agitation as medication changes could.

2. A nurse assisting with a childbirth class is discussing nonpharmacological strategies used during labor. Which of the following statements by a client indicates an understanding of cutaneous stimulation?

• A. Apply counter-pressure for back pain
• B. Use deep breathing exercises
• C. Visualize the baby's head
• D. Use massage therapy

Correct answer: A

Rationale: The correct answer is A: 'Apply counter-pressure for back pain.' Counter-pressure involves applying pressure to the lower back to alleviate pain during labor. This technique is a form of cutaneous stimulation, which can help with pain relief. Choice B, deep breathing exercises, is a form of relaxation technique and does not directly involve cutaneous stimulation. Choice C, visualizing the baby's head, is a mental imagery technique and does not involve physical stimulation of the skin. Choice D, massage therapy, is a tactile stimulation technique but is not specifically focused on back pain relief through counter-pressure.

3. A nurse is teaching a client how to administer enoxaparin. Which of the following instructions should the nurse include?

• A. Inject the medication into the muscle of the thigh
• B. Massage the injection site after administration
• C. Pinch the skin before injecting
• D. Administer the medication at the same time each day

Correct answer: C

Rationale: The correct instruction for administering enoxaparin is to pinch the skin before injecting. Pinching the skin helps create a proper fold for subcutaneous injections like enoxaparin, ensuring proper delivery of the medication into the subcutaneous tissue. Choice A is incorrect because enoxaparin should be administered subcutaneously, not into the muscle. Injecting it into the muscle can lead to complications. Choice B is incorrect because massaging the injection site after administration can increase the risk of bleeding or bruising due to the anticoagulant properties of enoxaparin. Choice D is incorrect as it is a general instruction and does not specifically relate to the administration of enoxaparin.

4. A nurse is providing teaching to a client who is to start taking digoxin. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should take this medication with food.
• B. I will contact my provider if my heart rate is below 60 beats per minute.
• C. I should take an antacid with this medication to prevent gastrointestinal upset.
• D. I will need to take this medication for 14 days.

Correct answer: B

Rationale: The client should contact their provider if their heart rate drops below 60 beats per minute, as this could indicate digoxin toxicity.

5. A nurse is caring for a client who has a chest tube following a thoracotomy. Which of the following findings should the nurse report to the provider?

• A. Drainage of 75 mL in the first hour after surgery.
• B. Constant bubbling in the water seal chamber.
• C. Tidaling in the water seal chamber.
• D. Client report of pain at the chest tube insertion site.

Correct answer: B

Rationale: Constant bubbling in the water seal chamber indicates an air leak, which should be reported to the provider. This finding suggests that the chest tube system is not functioning properly, leading to potential complications such as pneumothorax. Drainage of 75 mL in the first hour after surgery is within the expected range for a chest tube. Tidaling in the water seal chamber is a normal fluctuation and indicates proper functioning of the system. Client report of pain at the chest tube insertion site is expected after surgery and can be managed with appropriate pain management measures.

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