Nursing Elites

1. When administering an analgesic to a client with low back pain, which intervention should the practical nurse implement to promote the effectiveness of the medication?

• A. Massage the lower back and position the client in proper alignment
• B. Encourage the client to ambulate frequently and take deep breaths
• C. Assist the client in performing passive and active range of motion exercises
• D. Give medication with a full glass of water and offer high-fiber foods

Correct answer: A

Rationale: Massaging the lower back and positioning the client in proper alignment can help relieve muscle tension and enhance the effectiveness of analgesics by providing additional comfort and promoting better pain management. This intervention directly addresses the site of pain and can improve the medication's efficacy. Choices B, C, and D are incorrect because while they may have benefits in other situations, they are not directly related to promoting the effectiveness of analgesics in clients with low back pain. Encouraging ambulation and deep breathing, assisting with range of motion exercises, and offering water and high-fiber foods are important for overall patient care but are not specific to enhancing analgesic effectiveness in this context.

2. When administering IV fluids to a client with a history of congestive heart failure (CHF), what is the nurse's primary concern?

• A. Monitoring for signs of fluid overload.
• B. Ensuring the client receives enough fluids to prevent dehydration.
• C. Preventing electrolyte imbalances.
• D. Maintaining the prescribed rate of fluid administration.

Correct answer: A

Rationale: The primary concern when administering IV fluids to a client with a history of congestive heart failure (CHF) is monitoring for signs of fluid overload. Clients with CHF are particularly vulnerable to fluid overload, which can exacerbate their condition. Signs of fluid overload include edema and difficulty breathing. Therefore, the nurse must closely monitor these signs to prevent worsening of the client's condition. Choices B, C, and D are incorrect because while ensuring hydration, preventing electrolyte imbalances, and maintaining the prescribed rate of fluid administration are important, they are secondary concerns compared to the critical task of monitoring for fluid overload in a client with CHF.

3. A client with peripheral neuropathy due to cirrhosis is at risk for injury. What should the nurse do?

• 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 critical as peripheral neuropathy can lead to decreased sensation and increased risk of trauma. This measure helps prevent wounds, ulcers, and other complications. Applying a heating pad (Choice B) can worsen symptoms and cause burns due to decreased sensation. Keeping the client's feet elevated (Choice C) may help reduce swelling but does not directly address the risk of injury. Assessing for jaundice (Choice D) is important in cirrhosis but is not directly related to the client's risk of injury due to peripheral neuropathy.

4. A client who is post-operative from a carotid endarterectomy is experiencing difficulty swallowing. What is the nurse's priority action?

• A. Administer a prescribed antiemetic.
• B. Assess the client’s airway and respiratory status.
• C. Elevate the head of the bed.
• D. Encourage the client to take small sips of water.

Correct answer: B

Rationale: The correct answer is to assess the client’s airway and respiratory status (Choice B). Difficulty swallowing after carotid endarterectomy could indicate swelling or nerve damage affecting swallowing, which may compromise the airway. Assessing the airway and respiratory status is crucial to ensure the client's ability to breathe. Administering an antiemetic (Choice A) is not the priority as the primary concern is airway patency. Elevating the head of the bed (Choice C) can help with swallowing difficulties but does not address the immediate risk to the airway. Encouraging the client to take small sips of water (Choice D) is contraindicated if there is a risk of compromised airway due to swallowing difficulties.

5. A client has a prescription for a transcutaneous electrical nerve stimulator (TENS) unit for pain management during the postoperative period following a lumbar laminectomy. Which information should the PN reinforce about the action of the adjuvant pain modality?

• A. The discharge of electricity will distract the client's focus from the pain.
• B. An infusion of medication into the spinal canal will block pain perception.
• C. Pain perception in the cerebral cortex is dulled by the unit's discharge of an electrical stimulus.
• D. A mild electrical stimulus on the skin surface closes the gates of nerve conduction for severe pain.

Correct answer: D

Rationale: The TENS unit works by providing a mild electrical stimulus to the skin, which helps to 'close the gate' on pain signals, reducing the perception of pain. Choice A is incorrect because distraction is not the primary mechanism of action for TENS. Choice B is incorrect as it describes a different method of pain management involving medication infusion into the spinal canal. Choice C is incorrect as it inaccurately describes the location of pain perception modulation by the TENS unit.

Similar Questions