Nursing Elites

1. Six hours after major abdominal surgery, a male client complains of severe abdominal pain; is pale and perspiring; has a thready, rapid pulse; and states he feels faint. The nurse checks the client’s medication administration record and determines that the client receives another injection of pain medication in an hour. What is the appropriate action by the nurse?

• A. Explain to the client that it is too early to have an injection for pain
• B. Call the practitioner, report the client’s symptoms, and obtain further orders
• C. Reposition the client for greater comfort and turn on the television as a distraction
• D. Prepare the injection and administer it to the client early because of the severe pain

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to call the practitioner, report the client’s symptoms, and obtain further orders. The client's symptoms, including severe abdominal pain, pallor, perspiration, thready rapid pulse, and feeling faint, are indicative of potential complications like internal bleeding, which require immediate medical evaluation. Explaining to the client that it is too early for pain medication or repositioning the client for comfort are not appropriate actions given the severity of the symptoms. Administering the injection early without consulting the practitioner can be dangerous and may worsen the client's condition.

2. A nurse is caring for a client with a diagnosis of catatonic schizophrenia. What clinical finding does the nurse expect the client to exhibit?

• A. Crying
• B. Self-mutilation
• C. Immobile posturing
• D. Repetitive activities

Correct answer: C

Rationale: In catatonic schizophrenia, clients commonly exhibit immobile posturing, where they may maintain a fixed position for extended periods. This could include holding rigid poses or remaining motionless. Choice A, 'Crying,' is not typically associated with catatonic schizophrenia. Choice B, 'Self-mutilation,' refers to a different behavior seen in some mental health conditions but is not a characteristic feature of catatonic schizophrenia. Choice D, 'Repetitive activities,' does not align with the typical presentation of catatonic schizophrenia, which is characterized by motor abnormalities such as immobility rather than engaging in purposeful repetitive movements.

3. What is the FIRST step in providing health care for a patient?

• A. Obtain and interpret vital signs
• B. Determine the needs of the patient
• C. Develop a plan of care
• D. Obtain lab work and x-rays

Correct answer: B

Rationale: The correct first step in providing health care for a patient is to determine the needs of the patient. Understanding the patient's requirements, concerns, and medical history is crucial before proceeding with any further steps. Option A, 'Obtain and interpret vital signs,' may be necessary but typically follows assessing the patient's needs. Option C, 'Develop a plan of care,' comes after identifying the patient's needs. Option D, 'Obtain lab work and x-rays,' is usually done based on the patient's needs and the developed plan of care, making it a later step in the process.

4. For a patient on lithium therapy, which dietary recommendation is essential?

• A. Increase caffeine intake
• B. Increase sodium intake
• C. Increase protein intake
• D. Increase fiber intake

Correct answer: B

Rationale: The correct answer is to increase sodium intake. For patients on lithium therapy, maintaining consistent sodium intake is crucial to avoid fluctuations in drug levels. Increasing caffeine intake (choice A) is not recommended as it can interfere with lithium levels. While protein intake (choice C) is important for overall health, it is not specifically essential for patients on lithium therapy. Similarly, increasing fiber intake (choice D) is beneficial but not a primary concern for patients on lithium therapy.

5. The client diagnosed with diabetes mellitus type 2 is admitted to the hospital with cellulitis of the right foot secondary to an insect bite. Which intervention should the nurse implement first?

• A. Administer intravenous antibiotics
• B. Apply warm moist packs every two hours
• C. Elevate the right foot on two pillows
• D. Teach the client about skin and foot care

Correct answer: A

Rationale: Administering intravenous antibiotics is the priority intervention in this scenario. Cellulitis is a bacterial skin infection that requires prompt treatment with antibiotics to prevent its spread and potential complications. While warm moist packs and elevation can be beneficial as adjunct measures, they are not the initial priority. Teaching about skin and foot care is important, but it can be addressed after stabilizing the acute condition with antibiotics.

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