Nursing Elites

1. When assessing a client several hours after surgery, the nurse observes that the client grimaces and guards the incision while moving in bed. The client is diaphoretic, has a radial pulse rate of 110 beats/min, and a respiratory rate of 35 breaths/min. What assessment should the nurse perform first?

• A. Apical heart rate
• B. IV site and fluids
• C. Pain scale
• D. Temperature

Correct answer: C

Rationale: The client’s grimacing and guarding suggest pain; assessing the pain scale is crucial for addressing the discomfort. Pain management is a priority to ensure the client's well-being and comfort. Checking the apical heart rate, IV site and fluids, or temperature can be important but addressing the client's pain takes precedence in this scenario. The elevated pulse rate and respiratory rate could be indicative of pain, making the pain scale assessment essential to guide appropriate interventions.

2. A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 mmHg and he admits that he has not been taking the prescribed medication because the drugs make him feel bad. In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?

• A. Stroke secondary to hemorrhage
• B. Acute kidney injury due to glomerular damage
• C. Heart block due to myocardial damage
• D. Blindness secondary to cataracts

Correct answer: A

Rationale: The correct answer is A: Stroke secondary to hemorrhage. Hypertension increases the risk of stroke due to the stress and damage it causes to blood vessels, which can lead to hemorrhage. Choice B is incorrect because acute kidney injury is more commonly associated with chronic uncontrolled hypertension, not acute elevations. Choice C is incorrect as heart block is not a direct consequence of hypertension. Choice D is incorrect as hypertension does not directly cause cataracts leading to blindness.

3. The urinary drainage of a client with continuous bladder irrigation is becoming increasingly red. Which intervention should the nurse implement?

• A. Increase the irrigation rate
• B. Lower the head of the bed
• C. Milk the catheter tubing
• D. Evaluate for fluid overload

Correct answer: A

Rationale: Increasing the irrigation rate can help clear any blood clots and reduce the redness in the urinary drainage. This intervention aims to improve the flushing of the bladder and potentially resolve the issue. Lowering the head of the bed would not directly address the red urinary drainage. Milking the catheter tubing is not recommended as it can cause trauma to the catheter or bladder, leading to further complications. While evaluating for fluid overload is an important nursing consideration, it does not directly address the immediate concern of redness in the urinary drainage, which requires a focused intervention to clear any blockages or clots in the system.

4. A client with diabetic peripheral neuropathy has been taking pregabalin for 4 days. Which finding indicates to the nurse that the medication is effective?

• A. Granulating tissue in foot ulcer
• B. Full volume of pedal pulse
• C. Reduced level of pain
• D. Improved visual activity

Correct answer: C

Rationale: The correct answer is C: 'Reduced level of pain.' Pregabalin is used to manage neuropathic pain, so a reduction in pain indicates the medication's effectiveness in this case. Granulating tissue in a foot ulcer and the full volume of a pedal pulse are not direct indicators of pregabalin's effectiveness in managing neuropathic pain. Improved visual activity is not related to the effects of pregabalin in diabetic peripheral neuropathy.

5. What actions should the nurse take regarding an older adult male who had an abdominal cholecystectomy and has become increasingly confused and disoriented over the past 24 hours, found wandering into another client’s room and returned to his own room by the unlicensed assistive personnel (UAP)? (Select all that apply)

• A. Apply soft upper limb restraints and raise all four bed rails
• B. Report mental status change to the healthcare provider
• C. Assess the client’s breath sounds and oxygen saturation
• D. Assign the UAP to re-assess the client’s risk for falls

Correct answer: B

Rationale: In this situation, the appropriate action for the nurse to take is to report the mental status change to the healthcare provider. Confusion and disorientation post-surgery can be indicative of various factors, such as electrolyte imbalances or respiratory issues, necessitating comprehensive assessment by the healthcare team. Applying restraints and raising bed rails may not address the underlying cause of the confusion, and assigning the UAP to reassess the client's risk for falls does not directly address the cognitive changes observed.

Similar Questions