Nursing Elites

1. The client is 4 hours post-operative from a cesarean section and complains of gas pain and bloating. What non-pharmacological intervention can the nurse provide?

• A. Encourage the client to ambulate
• B. Apply a heating pad
• C. Provide a carbonated beverage
• D. Teach relaxation techniques

Correct answer: A

Rationale: The correct answer is to encourage the client to ambulate. Early ambulation helps alleviate gas pain and bloating by promoting gastrointestinal motility and reducing the accumulation of gas in the abdomen. Applying a heating pad may provide comfort for some types of pain but is not specifically effective for gas pain. Providing a carbonated beverage can actually worsen gas pain due to the introduction of more gas into the digestive system. Teaching relaxation techniques may be beneficial for overall comfort but may not directly address the gas pain and bloating experienced post-cesarean section.

2. The healthcare provider is preparing to administer an intramuscular injection to an adult client. Which site is the preferred location for this injection?

• A. Deltoid muscle.
• B. Vastus lateralis muscle.
• C. Ventrogluteal muscle.
• D. Dorsogluteal muscle.

Correct answer: C

Rationale: The ventrogluteal site is preferred for intramuscular injections in adults due to its muscle mass and lower risk of nerve injury. The deltoid muscle is more commonly used for vaccines in adults, the vastus lateralis muscle is preferred in infants and young children, and the dorsogluteal muscle is associated with a higher risk of nerve injury and is no longer recommended for intramuscular injections.

3. The nurse is assessing a client who has just received a blood transfusion. The client reports chills and back pain. What is the nurse's priority action?

• A. Slow the rate of transfusion.
• B. Administer an antipyretic.
• C. Stop the transfusion immediately.
• D. Notify the healthcare provider.

Correct answer: C

Rationale: The correct answer is C: Stop the transfusion immediately. Chills and back pain are indicative of a possible transfusion reaction, which is a critical situation. Stopping the transfusion is crucial to prevent further complications and ensure the client's safety. Slowing the rate of transfusion (Choice A) is not sufficient in this case as immediate action is required. Administering an antipyretic (Choice B) may help with fever but does not address the potential severe reaction. Notifying the healthcare provider (Choice D) can be done after stopping the transfusion, but the priority is to halt the infusion to prevent harm.

4. A client with a leg fracture reports increased pain and swelling. What should the nurse suspect?

• A. Compartment syndrome
• B. Deep vein thrombosis
• C. Wound infection
• D. All of the above

Correct answer: A

Rationale: Increased pain and swelling in a fracture could indicate compartment syndrome, a serious condition requiring urgent care. Compartment syndrome is characterized by increased pressure within a muscle compartment, leading to compromised blood flow and potential tissue damage. Deep vein thrombosis is less likely in this scenario as the symptoms are more indicative of compartment syndrome. Wound infection would typically present with localized signs of infection at the wound site, such as redness, warmth, and purulent drainage, rather than diffuse pain and swelling.

5. A client with a history of hypertension is prescribed lisinopril. Which potential side effect should the nurse monitor for?

• A. Hypokalemia
• B. Hyperglycemia
• C. Persistent cough
• D. Tachycardia

Correct answer: C

Rationale: The correct answer is C: Persistent cough. Lisinopril is an ACE inhibitor commonly associated with a persistent dry cough as a side effect. This cough is thought to result from increased bradykinin levels. Choices A, B, and D are incorrect. Hypokalemia is not a common side effect of lisinopril; in fact, it may lead to hyperkalemia. Hyperglycemia is not a typical side effect of lisinopril use. Tachycardia is also not a common side effect associated with ACE inhibitors like lisinopril.

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