Nursing Elites

1. The PN determines that a client with cirrhosis is experiencing peripheral neuropathy. What action should the PN take?

• A. Protect the client's feet from injury
• B. Apply a heating pad to the affected area
• C. Keep the client's feet elevated
• D. Assess the feet and legs for jaundice

Correct answer: A

Rationale: Protecting the client's feet from injury is the most appropriate action for a client with cirrhosis experiencing peripheral neuropathy. Peripheral neuropathy can lead to a loss of sensation, making the client prone to unnoticed injuries. Applying a heating pad (Choice B) is contraindicated as it may cause burns or further damage to the affected area. Keeping the client's feet elevated (Choice C) is not directly related to managing peripheral neuropathy and may not provide significant benefit. Assessing the feet and legs for jaundice (Choice D) is important for monitoring liver function in clients with cirrhosis, but in this case, the priority is to prevent injury to the feet due to decreased sensation.

2. What should the nurse do to complete a focused assessment for a female client with inflamed and painful hemorrhoids?

• A. Determine if the client uses any over-the-counter preparations for hemorrhoids
• B. Place the client in a standing position, leaning over the exam bed for inspection
• C. Position the client in the left lateral position to inspect the perineal area for fissures or sacs
• D. Ask the client how long she has experienced discomfort related to hemorrhoids

Correct answer: D

Rationale: Asking the client about the duration of discomfort related to hemorrhoids is the best intervention to implement for a focused assessment. This information provides important context for assessing the severity and chronicity of the condition, which is crucial for developing an appropriate care plan. Choices A, B, and C do not directly address the need to gather information about the duration of symptoms, which is essential for understanding the client's condition.

3. When caring for a patient with a chest tube, which nursing action is most important?

• A. Clamping the chest tube every 2 hours to prevent air leaks
• B. Keeping the drainage system below chest level
• C. Emptying the drainage system every hour to prevent backflow
• D. Removing the chest tube when drainage decreases significantly

Correct answer: B

Rationale: The most crucial nursing action when caring for a patient with a chest tube is to keep the drainage system below chest level (choice B). This position helps ensure proper drainage and prevents backflow of fluid or air into the pleural space, promoting optimal functioning of the chest tube. Clamping the chest tube every 2 hours (choice A) is incorrect as it can obstruct the drainage system and lead to complications. Emptying the drainage system every hour (choice C) is unnecessary unless there are specific clinical indications. Removing the chest tube when drainage decreases significantly (choice D) is also incorrect as the decision should be based on overall clinical assessment rather than drainage amount alone.

4. After a hip replacement surgery, a client is instructed to use an abduction pillow while in bed. What is the primary purpose of this device?

• A. To reduce the risk of blood clots.
• B. To prevent hip dislocation.
• C. To improve circulation in the legs.
• D. To alleviate pain and discomfort.

Correct answer: B

Rationale: The primary purpose of using an abduction pillow after hip replacement surgery is to prevent hip dislocation. The abduction pillow keeps the legs separated, which reduces the risk of hip dislocation by preventing excessive internal rotation and adduction of the hip joint. Choices A, C, and D are incorrect as the main goal of using the abduction pillow is to maintain proper positioning and stability of the hip joint to prevent dislocation, rather than addressing blood clots, circulation, or pain relief.

5. After administering pantoprazole to a client with gastroesophageal reflux disease (GERD), which statement by the client indicates to the nurse that the medication is producing the desired effect?

• A. After eating my meal, I did not experience any heartburn
• B. I have a great appetite and am feeling really hungry
• C. I should increase the amount of vitamin C in my diet
• D. While eating, I had no difficulty swallowing any of the foods

Correct answer: A

Rationale: The correct answer is A. Pantoprazole reduces stomach acid production, thus preventing the occurrence of heartburn after meals, which is a common symptom of GERD. Choice B is incorrect because an increased appetite and hunger are not indicators of the desired effect of pantoprazole. Choice C is unrelated to the medication's effect on GERD symptoms. Choice D is also incorrect because the absence of difficulty swallowing is not a specific indicator of pantoprazole's effectiveness in treating GERD.

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