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 with diabetes mellitus is scheduled for surgery. What is the nurse's priority action when preparing this client for surgery?

• A. Ensure the client is NPO before surgery
• B. Monitor the client's blood glucose levels
• C. Administer the client's insulin as scheduled
• D. Teach the client about postoperative care

Correct answer: B

Rationale: The correct answer is B: Monitor the client's blood glucose levels. Clients with diabetes are at risk for perioperative complications related to blood glucose fluctuations. Monitoring blood glucose levels is crucial to maintaining proper management before, during, and after surgery. Option A is not the priority action as ensuring NPO status is a standard preoperative procedure for all clients. Option C could be important but is secondary to monitoring blood glucose levels. Option D is important but not the priority during the preoperative phase.

3. A client is scheduled for surgery in the morning and is NPO. Which statement indicates that the client understands the reason for being NPO?

• A. Being NPO helps reduce the risk of nausea.
• B. I should not eat or drink anything to prevent complications during surgery.
• C. NPO reduces the risk of aspiration during surgery.
• D. NPO helps ensure the stomach is empty during surgery.

Correct answer: C

Rationale: The correct answer is C: 'NPO reduces the risk of aspiration during surgery.' When a client is NPO (nothing by mouth) before surgery, it is to prevent aspiration, which can lead to serious complications such as pneumonia. Choice A is incorrect because being NPO is more about preventing aspiration than nausea. Choice B is a general statement without specifying the reason for being NPO. Choice D is partially correct but does not emphasize the crucial aspect of preventing aspiration, which is the primary reason for fasting before surgery.

4. A client with Addison's disease becomes confused and weak. What is the nurse's first action?

• A. Administer a dose of hydrocortisone immediately.
• B. Check the client’s electrolyte levels.
• C. Administer a dose of normal saline.
• D. Measure the client’s blood pressure in both arms.

Correct answer: A

Rationale: The correct answer is to administer a dose of hydrocortisone immediately. In Addison's disease, confusion and weakness can be signs of an adrenal crisis. Administering hydrocortisone promptly is crucial to prevent further deterioration. Checking electrolyte levels (Choice B) is important but not the first action in managing an acute adrenal crisis. Administering normal saline (Choice C) is not the priority in this situation. Measuring blood pressure in both arms (Choice D) is not the initial action needed to address the client's confusion and weakness in Addison's disease.

5. A client with chronic obstructive pulmonary disease (COPD) is experiencing increased shortness of breath and fatigue. What is the nurse's first action?

• A. Administer a bronchodilator as prescribed.
• B. Check the client's oxygen saturation.
• C. Reposition the client to a high Fowler's position.
• D. Administer oxygen via nasal cannula.

Correct answer: B

Rationale: The correct first action for a client with COPD experiencing increased shortness of breath and fatigue is to check the client's oxygen saturation. This assessment helps the nurse evaluate the client's respiratory status promptly. Administering a bronchodilator (Choice A) may be necessary but should come after assessing the oxygen saturation. Repositioning the client to a high Fowler's position (Choice C) can help improve breathing but should not precede oxygen saturation assessment. Administering oxygen via nasal cannula (Choice D) may be needed based on the oxygen saturation results, but assessing it first is crucial.

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