Nursing Elites

1. The patient experienced a surgical procedure, and Betadine was utilized as the surgical prep. Two days postoperatively, the nurse's assessment indicates that the incision is red and has a small amount of purulent drainage. The patient reports tenderness at the incision site. The patient's temperature is 100.5°F, and the WBC is 10,500/mm³. Which action should the nurse take first?

• A. Reevaluate the temperature and white blood cell count in 4 hours.
• B. Check which solution was used for skin preparation in surgery.
• C. Plan to change the surgical dressing during the shift.
• D. Utilize SBAR to notify the primary health care provider.

Correct answer: D

Rationale: The patient is showing signs of a possible surgical site infection, including redness, purulent drainage, tenderness, elevated temperature, and increased white blood cell count. These symptoms suggest the need for immediate action to address a potential complication. Utilizing SBAR to notify the primary health care provider is crucial as it allows for effective communication of the patient's condition and the need for further assessment and intervention. Reevaluating the temperature and white blood cell count later, checking the solution used for skin preparation, or planning to change the dressing do not address the urgent need for intervention and communication with the healthcare provider.

2. A nurse is teaching an older adult client who has left-sided weakness about cane use. Which of the following instructions should the nurse include?

• A. Hold the cane with your left hand
• B. Move the cane forward 18 inches with each step
• C. When walking, move your left foot forward first
• D. Keep your elbow straight when you hold the cane

Correct answer: C

Rationale: The correct instruction for a client with left-sided weakness using a cane is to move the left foot forward first. This technique helps improve stability and safety by ensuring weight-bearing on the stronger side while providing support with the cane. Choice A is incorrect because the cane should be held on the stronger side, which is the right side in this case. Choice B is incorrect as the recommended distance to move the cane forward with each step is about 6 inches, not 18 inches. Choice D is incorrect as it is essential to maintain a slight bend in the elbow while using the cane to absorb shock and provide flexibility.

3. A nurse is reviewing the medication orders for a client with heart failure. Which of the following medications should the nurse clarify with the provider?

• A. Furosemide
• B. Spironolactone
• C. Digoxin
• D. Ibuprofen

Correct answer: D

Rationale: The correct answer is D, Ibuprofen. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can worsen heart failure due to its effects on renal function and fluid retention. Therefore, the nurse should clarify the use of Ibuprofen with the provider. Choices A, B, and C (Furosemide, Spironolactone, and Digoxin) are commonly prescribed medications for heart failure that help manage symptoms and improve cardiac function, so they do not need clarification in this scenario.

4. A client with a DNR order has requested resuscitation during a visit from the family. What is the nurse's best course of action?

• A. Follow the family's request and perform CPR.
• B. Explain to the family that the DNR must be honored.
• C. Call the healthcare provider to cancel the DNR order.
• D. Delay resuscitation until further clarification can be made.

Correct answer: B

Rationale: The correct course of action for the nurse is to explain to the family that the DNR (Do Not Resuscitate) order must be honored. It is essential for the nurse to uphold the client's wishes as documented in the DNR order. Performing CPR against the client's expressed wishes in the DNR order would violate ethical and legal standards. Calling the healthcare provider to cancel the DNR order without the client's consent is inappropriate and goes against the client's autonomy. Delaying resuscitation can be detrimental in an emergency situation and may not align with the client's wishes as outlined in the DNR order.

5. A home health nurse is teaching about chest physiotherapy (CPT) treatments to a client with COPD. Which of the following client statements should the nurse identify as an indication that the teaching has been understood?

• A. My coughing will decrease during CPT treatments.
• B. CPT treatments will decrease my respiratory infections.
• C. I will perform postural drainage after eating meals.
• D. CPT treatments will help cure my COPD.

Correct answer: B

Rationale: The correct answer is B because chest physiotherapy (CPT) helps reduce respiratory infections by loosening mucus in the lungs. Choice A is incorrect because coughing may temporarily increase during CPT treatments as mucus is being cleared. Choice C is incorrect because postural drainage is typically performed before meals. Choice D is incorrect because while CPT can help manage symptoms and improve lung function in COPD, it does not cure the disease.

Similar Questions