Nursing Elites

1. What intervention has the highest priority for a client with a fourth-degree midline laceration following the vaginal delivery of an 8-pound 10-ounce infant?

• A. Administer a prescribed stool softener
• B. Administer prescribed PRN sleep medications
• C. Encourage breastfeeding to promote uterine involution
• D. Encourage the use of prescribed analgesic perineal sprays

Correct answer: A

Rationale: Administering a prescribed stool softener is the highest priority intervention for a client with a fourth-degree midline laceration to prevent straining during bowel movements, which could potentially harm the healing laceration. Stool softeners help in maintaining soft stools, reducing the risk of injury to the suture line. Administering PRN sleep medications, encouraging breastfeeding, or promoting the use of analgesic perineal sprays are important aspects of care but are not the priority in this situation. Stool softeners play a crucial role in preventing complications and promoting healing in such cases, making it the most urgent intervention.

2. During a tonic-clonic seizure, what is the nurse's priority intervention?

• A. Insert an oral airway
• B. Administer oxygen via nasal cannula
• C. Restrain the client's arms and legs
• D. Protect the client's head from injury

Correct answer: D

Rationale: During a tonic-clonic seizure, the nurse's priority intervention is to protect the client's head from injury. This is crucial to prevent trauma, as head injuries can be severe during a seizure. Inserting an oral airway may cause injury or obstruction during the seizure and is not recommended. Administering oxygen via nasal cannula can be done after ensuring the client's safety. Restraining the client's arms and legs is also not recommended as it can lead to further injury or harm.

3. The nurse is caring for a client with a diagnosis of bipolar disorder who is taking lithium. What is the most important information the nurse should provide?

• A. Take the medication on an empty stomach.
• B. Monitor sodium intake.
• C. Report any signs of weight gain.
• D. Avoid excessive caffeine intake.

Correct answer: B

Rationale: The correct answer is B: 'Monitor sodium intake.' Sodium levels can affect lithium levels in the body, so it is crucial to maintain a consistent sodium intake to prevent toxicity or subtherapeutic levels. Option A is incorrect because lithium is usually recommended to be taken on an empty stomach to enhance absorption. Option C, reporting signs of weight gain, is relevant but not as critical as monitoring sodium intake. Option D, avoiding excessive caffeine intake, is important for some individuals but not as essential as monitoring sodium levels when taking lithium.

4. What is the most important aspect of colostomy care to teach the client?

• A. Change the colostomy bag daily
• B. Irrigate the colostomy daily
• C. Avoid high-fiber foods
• D. Assess the stoma for color and swelling

Correct answer: D

Rationale: The most crucial aspect of colostomy care to teach the client is to assess the stoma for color and swelling. This is essential to detect early signs of complications such as ischemia or infection. Changing the colostomy bag daily is important but not as critical as assessing the stoma for complications. Irrigating the colostomy daily is not a standard recommendation and should be performed based on healthcare provider's instructions. While avoiding high-fiber foods may be beneficial for some individuals with a colostomy, it is not the most important aspect of care compared to monitoring the stoma for complications.

5. The client with diabetes is being taught about the importance of foot care. Which statement by the client indicates a need for further teaching?

• A. ''I will inspect my feet daily for any cuts or blisters.''
• B. ''I will soak my feet in warm water every day.''
• C. ''I will wear shoes that fit properly to avoid injury.''
• D. ''I will avoid walking barefoot to protect my feet.''

Correct answer: B

Rationale: Choice B is the correct answer because soaking feet daily can lead to skin breakdown, making it inappropriate for clients with diabetes. Inspecting feet daily for cuts or blisters (Choice A), wearing properly fitting shoes (Choice C), and avoiding walking barefoot (Choice D) are all appropriate measures to maintain foot health for clients with diabetes.

Similar Questions