Nursing Elites

1. The client with a history of advanced chronic obstructive pulmonary disease (COPD) had conventional gallbladder surgery 2 days previously. Which intervention has priority for preventing respiratory complications?

• A. Incentive spirometry every 1 to 2 hours.
• B. Coughing and deep breathing every 1 to 2 hours.
• C. Getting the client out of bed 4 times daily as ordered by the physician.
• D. Giving oxygen at 4 L/minute according to the physician's order.

Correct answer: C

Rationale: The priority intervention for preventing respiratory complications in a client with advanced COPD who underwent gallbladder surgery is to get the client out of bed 4 times daily. This helps prevent pooling of secretions in the lungs and promotes better lung expansion. Incentive spirometry, coughing, and deep breathing are essential interventions; however, they should be performed more frequently, ideally every 1 to 2 hours, rather than every 4 hours or 4 times daily. Giving oxygen at 4 L/minute could potentially decrease the client's respiratory drive, which is not the priority in this case.

2. A client is complaining of difficulty walking secondary to a mass in the foot. The nurse should document this finding as:

• A. Plantar fasciitis.
• B. Hallux valgus.
• C. Hammertoe.
• D. Morton's neuroma.

Correct answer: D

Rationale: The correct answer is Morton's neuroma. Morton's neuroma is a small mass or tumor in a digital nerve of the foot, causing pain and difficulty walking. Hallux valgus is commonly known as a bunion, involving a bony bump at the base of the big toe. Hammertoe is a condition where one toe is bent abnormally at the middle joint, resembling a hammer. Plantar fasciitis is characterized by pain and inflammation in the arch of the foot, not by a mass causing difficulty walking. Therefore, options A, B, and C are incorrect as they do not describe a mass in the foot leading to difficulty walking, unlike Morton's neuroma.

3. What is the best nursing diagnosis for a client with newly diagnosed Diabetes Mellitus?

• A. Impaired Skin Integrity
• B. Knowledge Deficit: New Diabetes Diagnosis
• C. Alteration in Nutrition: More than Body Requirements
• D. Fluid Volume Deficit

Correct answer: B

Rationale: The correct answer is 'Knowledge Deficit: New Diabetes Diagnosis.' Newly diagnosed diabetics require education on their disease, medications, glucose testing, insulin injections, foot care, and sick-day plans. Choices A and D aim to prevent issues that do not currently exist for the client. Choice C, 'Alteration in Nutrition: More than Body Requirements,' is not the priority diagnosis for a newly diagnosed diabetic. While nutritional adjustments may be required for type I or type II diabetes, providing knowledge and education takes precedence at this stage.

4. A client is 36 hours post-op a TKR surgery. 270 cc of sero-sanguinous fluid accumulates in the surgical drains. What action should the nurse take?

• A. Notify the doctor
• B. Empty the drain
• C. Do nothing
• D. Remove the drain

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to notify the doctor. Significant sero-sanguinous drainage after TKR surgery could indicate a potential issue such as infection or bleeding. The physician needs to be informed promptly to assess the situation and determine the appropriate course of action. Emptying the drain, doing nothing, or removing the drain without consulting the physician could lead to complications going unnoticed or untreated. It is crucial to involve the physician in decision-making to ensure the best outcomes for the client.

5. After administering enoxaparin (Lovenox) subcutaneously into the abdomen, which action should the nurse take?

• A. Gently rub the injection site after removing the needle
• B. Have the client maintain a side-lying position for at least five minutes
• C. Remove the needle and engage the needle safety device
• D. Apply heat to the injection site

Correct answer: C

Rationale: After administering a subcutaneous injection of enoxaparin (Lovenox) into the abdomen, the nurse should remove the needle and engage the needle safety device. Rubbing the injection site after the needle is withdrawn is not recommended as it may cause irritation and bruising. Having the client maintain a side-lying position for at least five minutes is unnecessary for a subcutaneous injection into the abdomen. Applying heat to the injection site is not indicated after administering enoxaparin subcutaneously; it could increase the risk of bleeding or bruising at the injection site.

Similar Questions