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Which intervention will best help a patient with chronic pain maintain mobility?
- A. Provide the patient with opioids to control pain.
- B. Encourage stretching exercises to improve flexibility.
- C. Teach the patient to use assistive devices like a cane.
- D. Recommend complete bed rest until the pain subsides.
Correct Answer: B
Rationale: Encouraging stretching exercises is the most appropriate nursing intervention to help a patient with chronic pain maintain mobility. Stretching exercises can improve flexibility, prevent stiffness, and promote better range of motion in patients with chronic pain. Providing opioids (Choice A) may help control pain but does not directly address mobility. Teaching the patient to use assistive devices (Choice C) may be beneficial but does not focus on improving mobility directly. Recommending complete bed rest (Choice D) can lead to deconditioning and further loss of mobility, which is not recommended for chronic pain management.
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A nurse is preparing to administer a medication that requires a peak and trough level. What is the nurse's priority action?
- A. Administer the medication before the peak level is obtained.
- B. Withhold the medication until the trough level is obtained.
- C. Administer the medication based on the previous trough level.
- D. Ensure that the medication is administered within 2 hours of the peak level.
Correct Answer: B
Rationale: The nurse's priority action should be to withhold the medication until the trough level is obtained. This is crucial to ensure accurate dosing based on the patient's levels. Administering the medication before the peak level is obtained (choice A) can lead to incorrect dosing. Administering the medication based on the previous trough level (choice C) may not reflect the current levels accurately. Ensuring that the medication is administered within 2 hours of the peak level (choice D) is not necessary for obtaining accurate peak and trough levels.
A patient is receiving enteral feedings through a nasogastric (NG) tube. What is the most appropriate nursing intervention?
- A. Flush the NG tube with water before and after each feeding.
- B. Check the placement of the NG tube before each feeding.
- C. Administer medications through the NG tube every 4 hours.
- D. Increase the feeding rate if the patient is tolerating well.
Correct Answer: B
Rationale: Checking the placement of the NG tube before each feeding is crucial as it ensures the tube is correctly positioned, reducing the risk of complications such as aspiration or improper delivery of feedings. Flushing the NG tube with water before and after each feeding can disrupt the feeding schedule and is not a standard procedure. Administering medications through the NG tube every 4 hours may not be necessary for all patients and should be based on specific medication requirements. Increasing the feeding rate without proper assessment and monitoring can lead to feeding intolerance or complications, making it an inappropriate intervention.
A patient with a left arm fracture reports severe pain unrelieved by medication. What should the nurse assess for?
- A. Check for compartment syndrome
- B. Increase the pain medication
- C. Prepare the patient for surgery immediately
- D. Administer a sedative to calm the patient
Correct Answer: A
Rationale: Correct answer: When a patient with a left arm fracture reports severe pain unrelieved by medication, the nurse should assess for compartment syndrome. Compartment syndrome is a condition where increased pressure within a muscle compartment compromises circulation and can lead to tissue damage. It is a surgical emergency that requires immediate intervention. Choice B is incorrect because simply increasing pain medication without identifying the cause of the unrelieved pain may mask symptoms of a serious issue like compartment syndrome. Choice C is incorrect as surgery would only be necessary if compartment syndrome is confirmed. Choice D is incorrect as administering a sedative does not address the underlying issue of unrelieved pain and may delay appropriate treatment.
The emergency department has been notified of a potential bioterrorism attack. Which action by the nurse is priority?
- A. Prepare for potential posttraumatic stress related to this bioterrorism attack.
- B. Transport patients quickly and efficiently through the elevators.
- C. Monitor for specific symptoms related to the bioterrorism attack.
- D. Manage all patients using standard precautions.
Correct Answer: D
Rationale: During a potential bioterrorism attack, the priority for the nurse is to manage all patients using standard precautions. This approach ensures the safety of both patients and healthcare providers by preventing the spread of potential bioterrorism-related illnesses. Option A is incorrect because managing patient care and safety through standard precautions takes precedence. Option B is incorrect as patient transport should also be done while adhering to infection control measures. Option C is incorrect as monitoring for specific symptoms is important but not the priority when all patients need to be managed with standard precautions.
A patient with heart failure has gained 5 pounds in the last 3 days. What is the nurse's priority intervention?
- A. Restrict the patient's fluid intake.
- B. Monitor the patient's daily weight.
- C. Administer diuretics as prescribed.
- D. Increase the patient's salt intake to promote fluid balance.
Correct Answer: B
Rationale: The correct answer is to monitor the patient's daily weight. In heart failure, sudden weight gain indicates fluid retention, which can worsen the condition. Monitoring daily weight helps in early detection of fluid accumulation, allowing timely intervention. Restricting fluid intake (choice A) may be necessary but is not the priority at this point. Administering diuretics (choice C) should be done based on healthcare provider orders, not the nurse's independent decision. Increasing salt intake (choice D) is contraindicated in heart failure as it can exacerbate fluid retention.