Nursing Elites

1. A client is 2 days post-operative colon resection. After a coughing episode, the client's wound eviscerates. Which nursing action is most appropriate?

• A. Reinsert the protruding organ and cover with 4x4s
• B. Cover the wound with a sterile 4x4 and ABD dressing
• C. Cover the wound with a sterile saline-soaked dressing
• D. Apply an abdominal binder and manual pressure to the wound

Correct answer: B

Rationale: In the scenario where a client's wound eviscerates, the most appropriate nursing action is to cover the wound with a sterile saline-soaked dressing. Reinserting the protruding organ, as mentioned in choice A, is incorrect because it can lead to further complications requiring the client to return to surgery. Choice B, covering the wound with a sterile 4x4 and ABD dressing, is not ideal as it may not provide adequate protection and moisture for the exposed tissue. Choice D, applying an abdominal binder and manual pressure to the wound, is inappropriate as it does not address the specific needs of wound evisceration. Covering the wound with a sterile saline-soaked dressing helps maintain a moist environment, protects the exposed tissue, and prevents infection, promoting optimal wound healing and reducing the risk of complications.

2. Due to a high census, it has been necessary for a number of clients to be transferred to other units within the hospital. Which client should be transferred to the postpartum unit?

• A. A 66-year-old female with gastroenteritis
• B. A 40-year-old female with a hysterectomy
• C. A 27-year-old male with severe depression
• D. A 28-year-old male with ulcerative colitis

Correct answer: B

Rationale: The best client to transfer to the postpartum unit is the 40-year-old female with a hysterectomy. The nurses on the postpartum unit will be knowledgeable about postoperative care and can manage any complications related to the surgery. Choices A and D would be more appropriately cared for on a medical-surgical unit due to their conditions. Choice C should be transferred to a psychiatric unit for specialized care related to severe depression.

3. A client has been taking alprazolam (Xanax) for four years to manage anxiety. The client reports taking 0.5 mg four times a day. Which statement indicates that the client understands the nurse's teaching about discontinuing the medication?

• A. "I can drink alcohol now that I am decreasing my Xanax."?
• B. "I should not take another Xanax pill. Here is what is left of my last prescription."?
• C. "I should take three pills per day next week, then two pills for one week, then one pill for one week."?
• D. "I can expect to be sleepy for several days after stopping the medicine."?

Correct answer: C

Rationale: Explanation: When discontinuing alprazolam (Xanax) after long-term use, it is crucial to taper the dosage gradually to prevent withdrawal symptoms. The correct statement indicates an understanding of this by planning a structured decrease in dosage over time. Choice A is incorrect as drinking alcohol while decreasing Xanax can be dangerous and is not recommended. Choice B is incorrect as abruptly stopping Xanax is not safe and can lead to withdrawal symptoms. Choice D is incorrect as expecting to be sleepy for several days after stopping the medication does not address the need for a gradual tapering process to avoid withdrawal symptoms.

4. A client reports hearing voices. What should the nurse do next?

• A. Touch the client to help him return to reality.
• B. Leave the client alone until reality returns.
• C. Ask the client to describe what is happening.
• D. Tell the client there are no voices.

Correct answer: C

Rationale: When a client reports hearing voices, it might indicate hallucinations. It is essential for the nurse to ask the client to describe what is happening to gain a better understanding of the hallucinations. This approach helps in assessing the severity and content of the hallucinations, which can guide further interventions. Touching the client without consent can be intrusive and may escalate the situation, violating the client's personal space. Leaving the client alone may not address the underlying issue of hallucinations and can lead to potential risks if the client is distressed. Telling the client there are no voices denies their experience, invalidates their feelings, and can result in mistrust between the client and the nurse.

5. During a school screening, a nurse notices small bruises on the anterior and posterior ribs of an 8-year-old Asian child. The nurse should ask the child:

• A. if the family practices coining
• B. who performs coinings
• C. if the child has fallen
• D. how long the child has been abused

Correct answer: A

Rationale: The correct answer is to ask if the family practices coining. In Asian cultures, coining is a traditional practice believed to draw infections from the body. It involves rubbing a heated coin on the chest and torso, which can cause bruising similar to what the nurse noticed on the child's ribs. This question is important to differentiate between cultural practices and potential child abuse. Choices B, C, and D are incorrect because assuming abuse without considering cultural practices can lead to misinterpretation and inappropriate actions. It's crucial for healthcare providers to be culturally sensitive and gather all relevant information before making conclusions.

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