Nursing Elites

1. A young male client is admitted to rehabilitation following a right above-knee amputation (AKA) and reports aching in his right foot. Which intervention is most important for the nurse to implement?

• A. Encourage discussion about feelings of limb loss.
• B. Administer a prescription for gabapentin.
• C. Teach the client how to wrap the stump with an elastic bandage.
• D. Offer assistance to move to a quiet room to relax.

Correct answer: B

Rationale: The correct answer is B: Administer a prescription for gabapentin. Gabapentin is used to treat phantom limb pain, which is common after amputations. Encouraging discussion about feelings of limb loss (choice A) is important for emotional support but does not address the physical pain. Teaching the client how to wrap the stump with an elastic bandage (choice C) is not indicated for aching in the 'right foot' as described. Offering assistance to move to a quiet room to relax (choice D) may provide comfort but does not address the underlying issue of phantom limb pain.

2. A client who had a vasectomy is in the post-recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse?

• A. Until the healthcare provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception.
• B. This procedure doesn't impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen, and no sperm are in your ejaculate.
• C. After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesn't involve hard physical labor, you can return to your job as soon as you feel up to it. The stitches generally dissolve in seven to ten days.
• D. The healthcare provider at this clinic recommends rest, ice, an athletic supporter, or over-the-counter pain medication to relieve any discomfort.

Correct answer: A

Rationale: The most important point to reinforce after a vasectomy is to continue using contraception until the healthcare provider confirms the absence of sperm in the ejaculate. Choice A is correct because it emphasizes the necessity of another form of contraception until sperm absence is confirmed. Choice B is incorrect because it focuses on how a vasectomy works anatomically rather than the need for ongoing contraception. Choice C is incorrect as it discusses post-vasectomy care but does not address the need for continued contraception. Choice D is also incorrect as it refers to general post-procedure recommendations but does not highlight the crucial aspect of using contraception until sperm absence is confirmed.

3. A client with heart failure is prescribed digoxin and reports nausea. What is the nurse's first action?

• A. Administer an anti-nausea medication as prescribed.
• B. Assess the client's digoxin level immediately.
• C. Assess the client’s apical pulse and hold the next dose if it's below 60 bpm.
• D. Instruct the client to reduce their fluid intake.

Correct answer: B

Rationale: When a client on digoxin reports nausea, it can be a sign of digoxin toxicity. The priority action for the nurse is to assess the client's digoxin level immediately. This assessment will help determine if the nausea is related to digoxin toxicity, requiring a dosage adjustment. Administering an anti-nausea medication (Choice A) does not address the underlying issue of potential digoxin toxicity. Assessing the client's apical pulse (Choice C) is important in general digoxin monitoring but not the first action when nausea is reported. Instructing the client to reduce fluid intake (Choice D) is not the initial response to nausea in a client taking digoxin.

4. Which task could be safely delegated by the nurse to an unlicensed assistive personnel (UAP)?

• A. Accompanying a client who self-administers insulin
• B. Cleansing and dressing a small decubitus ulcer
• C. Monitoring a client's response to passive range of motion exercises
• D. Applying and caring for a client's rectal pouch

Correct answer: D

Rationale: The correct answer is D because tasks like applying and caring for a client's rectal pouch are within the UAP's scope of practice, as they do not require clinical judgment. Choices A, B, and C involve more complex assessments or interventions that require clinical judgment and should be performed by licensed nursing staff.

5. A client with deep vein thrombosis (DVT) is prescribed heparin. What lab value should the nurse monitor to assess the effectiveness of the therapy?

• A. Prothrombin time (PT).
• B. Partial thromboplastin time (PTT).
• C. International Normalized Ratio (INR).
• D. Hemoglobin and hematocrit.

Correct answer: B

Rationale: The correct answer is B: Partial thromboplastin time (PTT). PTT is the lab value used to monitor the effectiveness of heparin therapy in clients with DVT. It measures the intrinsic pathway of coagulation and is prolonged by heparin therapy. Prothrombin time (PT) and International Normalized Ratio (INR) are primarily used to monitor warfarin therapy, not heparin. Checking hemoglobin and hematocrit levels is important but does not directly assess the effectiveness of heparin therapy in DVT.

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