Nursing Elites

1. Which intervention should the nurse include in the plan of care for a patient with tetanus?

• A. Open window shades to provide natural light
• B. Encourage coughing and deep breathing
• C. Minimize the amount of stimuli in the room
• D. Reposition from side to side every hour

Correct answer: C

Rationale: The correct intervention for a patient with tetanus is to minimize the amount of stimuli in the room. Tetanus can lead to muscle spasms and heightened sensitivity to stimuli, making it essential to reduce environmental triggers for the patient's comfort and safety. Opening window shades for natural light (Choice A) may exacerbate sensitivity to light and worsen symptoms. Encouraging coughing and deep breathing (Choice B) is not directly related to managing tetanus symptoms. While repositioning the patient every hour (Choice D) is important for preventing pressure ulcers, it is not the priority when managing tetanus, which requires a quiet, low-stimulus environment to minimize muscle spasms and discomfort.

2. What action should the nurse take after a client produces the first of a series of sputum samples for cytology?

• A. Ensure the client remains NPO until all samples are collected
• B. Transport the sputum container to the laboratory in a biohazard bag
• C. Discard the initial sample and document the time it was obtained
• D. Document the time the client last ate or drank on the laboratory slip

Correct answer: B

Rationale: The correct action for the nurse to take after a client produces the first of a series of sputum samples for cytology is to transport the sputum container to the laboratory in a biohazard bag. This is important to ensure proper handling and prevent contamination of the sample. Choice A is incorrect because there is no need to keep the client NPO until all samples are collected. Choice C is incorrect as the initial sample should not be discarded but rather transported to the laboratory. Choice D is also incorrect as documenting the time the client last ate or drank is not directly relevant to the immediate action needed for the sputum sample.

3. An adult client with a broken femur is transferred to the medical-surgical unit to await surgical internal fixation after the application of an external traction device to stabilize the leg. An hour after an opioid analgesic was administered, the client reports muscle spasms and pain at the fracture site. While waiting for the client to be transported to surgery, which action should the nurse implement?

• A. Observe for signs of deep vein thrombosis.
• B. Administer a PRN dose of a muscle relaxant.
• C. Check the client’s most recent electrolyte values.
• D. Reduce the weight on the traction device.

Correct answer: B

Rationale: The correct answer is B: Administer a PRN dose of a muscle relaxant. Muscle spasms and pain might be relieved by muscle relaxants, which are appropriate before surgery. Choice A is incorrect because the client is experiencing muscle spasms, not signs of deep vein thrombosis. Choice C is not the most immediate action needed in this situation. Choice D is incorrect because reducing the weight on the traction device would not directly address the muscle spasms and pain reported by the client.

4. The client who had a below-the-knee (BKA) amputation is being prepared for discharge to home. Which recommendation should the nurse provide this client?

• A. Inspect skin for redness
• B. Use a residual limb shrinker
• C. Apply alcohol to the stump after bathing
• D. Wash the stump with soap and water

Correct answer: D

Rationale: The correct recommendation for a client with a below-the-knee amputation preparing for discharge is to wash the stump with soap and water. This helps maintain cleanliness and prevent infection. Inspecting the skin for redness is important to monitor for signs of infection, but it is not a specific recommendation for a BKA amputation. Using a residual limb shrinker can aid in shaping and reducing swelling in the residual limb but is not usually done immediately after a BKA amputation. Applying alcohol to the stump after bathing is not recommended as it can lead to skin irritation and dryness.

5. Following rectal surgery, a female client is very anxious about the pain she may experience during defecation. The nurse should collaborate with the healthcare provider to administer which type of medication?

• A. Bulk-forming agent
• B. Antianxiety agent
• C. Stool softener
• D. Stimulant cathartic

Correct answer: C

Rationale: After rectal surgery, a stool softener is the most appropriate medication to help prevent pain and straining during defecation. Stool softeners work by increasing the water content of the stool, making it easier to pass without discomfort. Bulk-forming agents (Choice A) help add mass to the stool but may not address the immediate post-operative discomfort. Antianxiety agents (Choice B) would address the anxiety but not the physical discomfort. Stimulant cathartics (Choice D) are not recommended after rectal surgery as they can cause cramping and increased bowel movements, potentially exacerbating pain.

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