Nursing Elites

1. The nurse is caring for a client who is 4 hours post-operative from abdominal surgery. The client is complaining of severe pain. What is the nurse's first action?

• A. Reassess the pain and its characteristics
• B. Administer prescribed pain medication
• C. Notify the surgeon
• D. Encourage the use of relaxation techniques

Correct answer: A

Rationale: The correct first action for the nurse to take when a post-operative client complains of severe pain is to reassess the pain and its characteristics. Reassessment is crucial to understand the nature and intensity of the pain, which will guide the nurse in providing appropriate interventions. Administering pain medication may be necessary but should only be done after reassessment to ensure the right medication and dose are given. Notifying the surgeon may be required in certain situations, but reassessment of pain should precede this action. Encouraging relaxation techniques is not the priority when a client is experiencing severe pain post-operatively.

2. The nurse is caring for a client with increased intracranial pressure (ICP). Which position should the nurse avoid?

• A. Keeping the head of the bed elevated at 30 degrees
• B. Positioning the client in the prone position
• C. Placing the client in a lateral recumbent position
• D. Elevating the client's legs

Correct answer: B

Rationale: The correct answer is B: Positioning the client in the prone position. Placing the client in the prone position should be avoided in a client with increased intracranial pressure (ICP) as it can further raise ICP. The prone position can hinder venous return and increase pressure within the cranial vault, potentially worsening the client's condition. Keeping the head of the bed elevated at 30 degrees helps promote venous drainage and reduce ICP. Placing the client in a lateral recumbent position can also assist in reducing ICP by optimizing cerebral perfusion. Elevating the client's legs can help improve venous return and maintain adequate cerebral blood flow, making it a suitable positioning intervention for managing increased ICP.

3. The nurse is providing discharge teaching to a client with newly diagnosed type 2 diabetes mellitus. Which instruction is most important to prevent complications?

• A. Monitor blood glucose levels regularly
• B. Maintain a low-fat diet
• C. Exercise regularly
• D. Take medication as prescribed

Correct answer: A

Rationale: Regular monitoring of blood glucose levels is crucial in managing diabetes and preventing complications. This allows the client and healthcare team to make timely adjustments to the treatment plan. While maintaining a low-fat diet, exercising regularly, and taking medication as prescribed are all important aspects of diabetes management, monitoring blood glucose levels takes precedence as it provides real-time information about the client's condition and helps prevent acute complications.

4. A client with diabetes mellitus is scheduled for surgery. What is the most important preoperative instruction the nurse should provide?

• A. Take your insulin as usual
• B. Do not eat or drink after midnight
• C. Monitor your blood glucose closely
• D. Bring your glucose meter to the hospital

Correct answer: B

Rationale: The most important preoperative instruction for a client with diabetes mellitus scheduled for surgery is to instruct them not to eat or drink after midnight. This instruction is crucial to maintain NPO (nothing by mouth) status before surgery, reducing the risk of aspiration during anesthesia. While taking insulin as usual (Choice A) is important, doses can be adjusted by the healthcare team. Monitoring blood glucose closely (Choice C) is essential but not as critical preoperatively. Bringing a glucose meter to the hospital (Choice D) can be helpful but is not as vital as maintaining NPO status.

5. A client is being treated for dehydration. Which clinical finding would indicate that treatment is effective?

• A. Dry mucous membranes
• B. Increased urine output
• C. Tachycardia
• D. Hypotension

Correct answer: B

Rationale: The correct answer is B: Increased urine output. When a client is being treated for dehydration, increased urine output is a positive indication that the treatment is effective. This signifies that the body is beginning to rehydrate and eliminate excess fluid. Choices A, C, and D are incorrect because dry mucous membranes, tachycardia, and hypotension are all associated with dehydration and would not be signs of effective treatment.

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