Nursing Elites

1. The nurse is caring for a postoperative client who is reluctant to ambulate. What strategy should the nurse use to encourage the client?

• A. Explain the benefits of ambulation for recovery
• B. Wait for the client to request to walk
• C. Tell the client that walking is necessary for discharge
• D. Offer pain medication before walking

Correct answer: A

Rationale: Corrected Rationale: The correct strategy for the nurse to encourage the postoperative client to ambulate is to explain the benefits of ambulation for recovery. Educating the client on how ambulation aids in preventing complications and promotes faster recovery can motivate their participation. Choice B is incorrect because waiting for the client to request to walk may lead to delays in mobilization. Choice C is incorrect as it may induce unnecessary fear in the client. Choice D is incorrect as offering pain medication before walking does not address the client's reluctance to ambulate.

2. Prior to administering morphine sulfate (Morphine), the nurse takes the client's vital signs. Based on which finding should the nurse withhold administration of the medication until the charge nurse is notified?

• A. Temperature of 100.8°F
• B. A pulse rate of 150 beats per minute
• C. A respiratory rate of 10 breaths per minute
• D. A blood pressure of 180/110

Correct answer: C

Rationale: The correct answer is C because a low respiratory rate is a critical concern when administering opioids like morphine, as they can suppress breathing. A high pulse rate (choice B) and high blood pressure (choice D) are not immediate contraindications for administering morphine. A slightly elevated temperature (choice A) may not necessarily require withholding morphine.

3. A client is admitted with a diagnosis of pneumonia. Which intervention should the nurse implement to promote airway clearance?

• A. Administer bronchodilators as prescribed.
• B. Encourage increased fluid intake.
• C. Perform chest physiotherapy.
• D. Provide humidified oxygen.

Correct answer: B

Rationale: Encouraging increased fluid intake is the most appropriate intervention to promote airway clearance in a client with pneumonia. Adequate hydration helps to thin respiratory secretions, making it easier for the client to cough up and clear the airways. Administering bronchodilators (Choice A) may help with bronchospasm but does not directly promote airway clearance. Chest physiotherapy (Choice C) can be beneficial in certain cases but may not be the initial intervention for promoting airway clearance. Providing humidified oxygen (Choice D) can help improve oxygenation but does not specifically target airway clearance in pneumonia.

4. The client with newly diagnosed peptic ulcer disease (PUD) is being taught about lifestyle modifications. Which instruction should be included?

• A. Increase the intake of spicy foods
• B. Avoid the use of nonsteroidal anti-inflammatory drugs (NSAIDs)
• C. Drink coffee in moderation
• D. Eat large meals at bedtime

Correct answer: B

Rationale: The correct instruction to include when teaching a client with newly diagnosed PUD about lifestyle modifications is to avoid the use of nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs can exacerbate peptic ulcer disease by causing further irritation of the gastric mucosa. Increasing the intake of spicy foods (choice A) can aggravate the condition by irritating the stomach lining. Drinking coffee (choice C) can stimulate gastric acid secretion, which may worsen the symptoms of PUD. Eating large meals at bedtime (choice D) can also exacerbate PUD by increasing gastric acid production when the body is at rest, potentially leading to discomfort and symptoms.

5. What should the nurse prioritize when providing discharge instructions to a client with a new colostomy?

• A. Skin care around the stoma site
• B. The schedule for colostomy bag replacement
• C. Techniques for odor control
• D. Dietary modifications

Correct answer: A

Rationale: Correct answer: Skin care around the stoma site. Proper skin care around the stoma site is crucial for preventing skin irritation and infection, which are common issues for patients with new colostomies. While the schedule for colostomy bag replacement (Option B) is important, it is not the priority during initial discharge instructions. Techniques for odor control (Option C) are relevant but secondary to skin care for a new colostomy. Dietary modifications (Option D) may be discussed later but are not the priority at this stage.

Similar Questions