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. What are appropriate nursing strategies to assist a client in maintaining a sense of self?

• A. Addressing the client by their first name when interacting with them
• B. Treating the client with dignity
• C. Explaining procedures to the client regardless of their attentiveness
• D. Encouraging the use of personal items to foster a sense of identity

Correct answer: B

Rationale: Maintaining a sense of self is crucial for clients in healthcare settings. Treating the client with dignity is a fundamental nursing principle that helps preserve the client's self-worth and identity. Addressing the client by their first name when interacting with them is a way to show respect, but it alone may not significantly contribute to maintaining their sense of self. Explaining procedures to the client, regardless of their attentiveness, is essential for informed consent and autonomy, empowering them in their care. Encouraging the use of personal items can foster a sense of identity as these items often hold personal significance and emotional value for the client, thus supporting their sense of self; therefore, discouraging their use would be counterproductive in maintaining a client's sense of self.

3. A 57-year-old woman is recently widowed. She states, "I will never be able to learn how to manage the finances. My husband did all of that."? Select the nurse's response that could help raise the client's self-esteem.

• A. "You feel inadequate because you have never learned to balance a checkbook."?
• B. "You should have insisted your husband teach you about the finances."?
• C. "You are strong and will learn how to manage your finances after a while."?
• D. "I believe in your strength to learn how to manage your finances in time."?

Correct answer: C

Rationale: The nurse should aim to boost the client's self-esteem by providing positive reinforcement. By stating, "You are strong and will learn how to manage your finances after a while,"? the nurse acknowledges the client's strength and capability, encouraging her to believe in herself. Choice A is incorrect as it focuses on the client's inadequacy rather than empowering her. Choice B places unnecessary blame on the client for not taking action in the past. Choice D, though positive, slightly alters the nurse's original phrase, making choice C the most appropriate response to uplift the client's self-esteem.

4. A client can receive the mumps, measles, rubella (MMR) vaccine if he or she:

• A. is pregnant.
• B. is immunocompromised.
• C. is allergic to neomycin.
• D. has a cold.

Correct answer: D

Rationale: A client can receive the MMR vaccine if he or she has a cold. A simple cold without fever does not preclude vaccination. Pregnant women and immunocompromised individuals cannot receive the MMR vaccine due to the live rubella component, which may lead to birth defects or disease. Choice C is incorrect because individuals with anaphylactic reactions to neomycin should not receive the measles vaccine according to the American Academy of Pediatrics.

5. During discharge teaching for a client with diverticulitis on a low-roughage diet, which food should be eliminated from the diet?

• A. Roasted chicken
• B. Noodles
• C. Cooked broccoli
• D. Custard

Correct answer: C

Rationale: The client with diverticulitis needs to avoid gas-forming foods that can increase abdominal discomfort. Cooked broccoli is a high-fiber food that can worsen symptoms. Roasted chicken, noodles, and custard are suitable choices for a low-roughage diet as they are less likely to cause gas formation or abdominal discomfort.

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