Nursing Elites

1. A nurse is caring for a postoperative client following knee arthroplasty who requires thigh-high compression sleeves. What should the nurse do?

• A. Make sure two fingers can fit under the sleeve.
• B. Apply the sleeve tightly to prevent blood clots.
• C. Ensure the sleeve is snug and comfortable.
• D. Check that the sleeve is loose enough to avoid constriction.

Correct answer: A

Rationale: The correct answer is to make sure two fingers can fit under the sleeve. This allows for proper circulation and ensures that the sleeve is not too tight, which can lead to complications such as impaired blood flow or tissue damage. Choice B is incorrect because applying the sleeve tightly can actually cause harm rather than prevent blood clots. Choice C is incorrect as snugness alone may not guarantee proper fit. Choice D is incorrect as a sleeve that is too loose can be ineffective in providing the necessary compression.

2. A nurse is preparing to administer ketorolac 0.5 mg/kg IV bolus every 6 hr to a school-age child who weighs 66 lb. The available ketorolac injection is 30 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

• A. 0.5 mL
• B. 1 mL
• C. 1.5 mL
• D. 2 mL

Correct answer: A

Rationale: To calculate the dose, first convert the weight from pounds to kilograms. The child weighs 66 lb, which is approximately 30 kg. The prescribed dose is 0.5 mg/kg, so for a 30 kg child, the dose would be 0.5 mg/kg x 30 kg = 15 mg. Since the available ketorolac injection is 30 mg/mL, the nurse should administer 15 mg ÷ 30 mg/mL = 0.5 mL per dose. Therefore, choice A (0.5 mL) is the correct answer. Choices B, C, and D are incorrect as they do not accurately calculate the correct dose based on the child's weight and the concentration of the ketorolac injection.

3. A nurse is caring for a client who has a new prescription for tube feeding. The nurse understands that the provider prescribed tube feeding because the client:

• A. Is unable to swallow foods by mouth
• B. Has a gastrointestinal obstruction
• C. Requires additional caloric intake to support healing
• D. Is at risk for aspiration

Correct answer: A

Rationale: The correct answer is A: 'Is unable to swallow foods by mouth.' Tube feeding is prescribed when a client is unable to safely swallow food by mouth but has a functional gastrointestinal tract. Option B, 'Has a gastrointestinal obstruction,' is incorrect as tube feeding is not typically prescribed for this reason. Option C, 'Requires additional caloric intake to support healing,' is incorrect because tube feeding is specifically for clients who are unable to swallow. Option D, 'Is at risk for aspiration,' is also incorrect as tube feeding would not be the primary intervention for aspiration risk; other strategies to reduce aspiration risk would be implemented instead.

4. Which goal is most appropriate for a patient who has had a total hip replacement?

• A. The patient will ambulate briskly on the treadmill by the time of discharge.
• B. The patient will walk 100 feet using a walker by the time of discharge.
• C. The nurse will assist the patient to ambulate in the hall 2 times a day.
• D. The patient will ambulate by the time of discharge.

Correct answer: B

Rationale: The goal 'The patient will walk 100 feet using a walker by the time of discharge' is the most appropriate goal for a patient who has had a total hip replacement because it is specific, measurable, achievable, and individualized. This goal sets a clear target for the patient's mobility progress post-surgery. Choice A is too vague and does not provide a specific target distance or method of ambulation. Choice C focuses on the nurse's actions rather than the patient's progress. Choice D lacks specificity in terms of distance or assistance required, making it less measurable and individualized compared to Choice B.

5. A client with type 1 diabetes mellitus is resistant to learning self-injection of insulin. Which of the following statements should the nurse make?

• A. Ask, 'Tell me what I can do to help you overcome your fear of giving yourself injections.'
• B. Instruct, 'You need to learn how to give yourself insulin injections immediately.'
• C. State, 'Insulin injections are important for managing your diabetes, so you must learn them.'
• D. Mention, 'Many people with diabetes manage well with insulin injections.'

Correct answer: A

Rationale: The correct answer is A. Asking the client what can be done to help overcome the fear of self-injections demonstrates empathy, understanding, and a willingness to support the client in addressing their barriers. This approach facilitates open communication, acknowledges the client's feelings, and involves them in the decision-making process. Choices B and C are authoritarian and may increase resistance in the client by being directive and not considering the client's perspective. Choice D, while positive, does not directly address the client's fear and resistance to self-injections, missing the opportunity to explore the underlying issues.

Similar Questions