Nursing Elites

1. While changing the dressing of a client with a leg ulcer, the nurse observes a red, tender, and swollen wound at the site of the lesion. Before reporting this finding to the healthcare provider, the nurse should note which of the client’s laboratory values?

• A. Neutrophil count.
• B. Hematocrit.
• C. Blood pH.
• D. Serum potassium and sodium.

Correct answer: A

Rationale: The correct answer is A: Neutrophil count. Neutrophil count helps assess for infection, which is indicated by the redness, tenderness, and swelling of the wound. Elevated neutrophil count is a common sign of bacterial infection. Hematocrit (choice B) measures the proportion of blood volume that is occupied by red blood cells and is not directly related to wound infection. Blood pH (choice C) and serum potassium and sodium (choice D) are important for assessing acid-base balance and electrolyte levels but are not the primary indicators of wound infection.

2. A client with a history of chronic pain requests a nonopioid analgesic. The client is alert but has difficulty describing the exact nature and location of the pain to the nurse. What action should the nurse implement next?

• A. Administer the analgesic as requested.
• B. Request a pain assessment from another nurse.
• C. Ask the client to describe the pain more precisely.
• D. Delay administration until the pain is better described.

Correct answer: D

Rationale: The correct action for the nurse to implement next is to delay administration until the pain is better described. It is essential to have a clear understanding of the nature and location of the pain before administering any analgesic to ensure appropriate and effective pain management. Requesting a pain assessment from another nurse or asking the client to describe the pain more precisely would also be appropriate actions to obtain more information before administering the analgesic. Administering the analgesic as requested without a clear description of the pain may not address the client's needs effectively and could potentially lead to ineffective pain management.

3. Before selecting which medication to administer, which action should the nurse implement if a postoperative client reports incisional pain and has two prescriptions for PRN analgesia?

• A. Compare the client’s pain scale rating with the prescribed dosing.
• B. Determine which prescription will have the quickest onset of action.
• C. Ask the client to choose which medication is needed for the pain.
• D. Document the client’s report of pain in the electronic medical record.

Correct answer: A

Rationale: When a postoperative client reports incisional pain and has two prescriptions for PRN analgesia, the nurse should first compare the client’s pain scale rating with the prescribed dosing. This action ensures that the client receives the appropriate medication based on their pain level. Determining the onset of action or asking the client to choose the medication does not guarantee that the right medication is administered according to the pain intensity. Documenting the pain report is important but should not be the first action when deciding which medication to administer.

4. The nurse is caring for a newborn with a myelomeningocele. Before surgery, what should the nursing interventions include?

• A. Leaving the lesion uncovered and placing the infant supine
• B. Covering the lesion with a sterile, saline-soaked gauze
• C. Applying lotion to the lesion to keep it moist
• D. Covering the lesion with a dry, sterile gauze

Correct answer: B

Rationale: The correct intervention before surgery for a newborn with a myelomeningocele is to cover the lesion with a sterile, saline-soaked gauze. This helps protect the exposed spinal cord and meninges from infection and damage. Choice A is incorrect because leaving the lesion uncovered can increase the risk of infection. Choice C is incorrect because applying lotion can introduce contaminants to the lesion. Choice D is incorrect because covering the lesion with a dry gauze can lead to adherence of the gauze to the wound, causing trauma upon removal and disrupting the healing process.

5. On the first postoperative day, the nurse finds an older male client disoriented and trying to climb over the bed railing. Previously, he was oriented to person, place, and time on admission. Which intervention should the nurse implement first?

• A. Administer a sedative.
• B. Determine the client’s blood pressure.
• C. Apply soft restraints.
• D. Call for assistance.

Correct answer: B

Rationale: The correct intervention the nurse should implement first is to determine the client’s blood pressure. Assessing the blood pressure is crucial in this situation to rule out physiological causes like hypotension leading to the client's disorientation. Administering a sedative (Choice A) without understanding the underlying cause may worsen the situation. Applying soft restraints (Choice C) should not be the initial action and can be considered later if necessary. Calling for assistance (Choice D) may be needed eventually, but assessing the client's blood pressure takes precedence to address the immediate concern.

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