Nursing Elites

1. A client is post-operative day one following an open cholecystectomy. The nurse notices the client's drainage from the T-tube is dark green. What is the most appropriate action for the nurse to take?

• A. Document the finding as normal.
• B. Notify the healthcare provider immediately.
• C. Decrease the suction on the T-tube.
• D. Flush the T-tube with saline to ensure patency.

Correct answer: A

Rationale: Dark green drainage from a T-tube after a cholecystectomy is bile, which is an expected finding. Bile is normally dark green in color. It is important for the nurse to recognize this as a normal post-operative occurrence and document the finding. There is no need to notify the healthcare provider immediately as this finding is an anticipated part of the client's recovery. Decreasing the suction on the T-tube or flushing it with saline is unnecessary and may not be indicated based on the color of the drainage. Therefore, the most appropriate action for the nurse to take is to document the dark green drainage as a normal finding.

2. The nurse is teaching a client with diabetes mellitus how to differentiate between hypoglycemia and ketoacidosis. What statement indicates to the nurse that the client has an understanding of this condition?

• A. Glucose should be taken if I have a fruity breath odor.
• B. Glucose should be taken if I am urinating more than usual.
• C. Glucose should be taken if I have blurred vision.
• D. Glucose should be taken if I develop shakiness.

Correct answer: D

Rationale: The correct answer is D. Shakiness is a symptom of hypoglycemia, which is low blood sugar. Taking glucose can help raise blood sugar levels quickly in this situation. Fruity breath odor and excessive urination are signs of ketoacidosis, a complication of diabetes involving high levels of ketones in the blood. Blurred vision can be a symptom of high blood sugar, but it is not specific to hypoglycemia.

3. When preparing a sterile field for a procedure, which action should the nurse take to maintain sterility?

• A. Place sterile items around the sterile field
• B. Keep hands below waist level to avoid contamination
• C. Open the sterile package away from the body
• D. Avoid reaching over the sterile field

Correct answer: D

Rationale: To maintain sterility when preparing a sterile field, it is essential to avoid reaching over the sterile field. This action can introduce contaminants from the nurse's clothing or unsterile areas, compromising the sterility of the field. Placing sterile items around the sterile field (choice A) is incorrect as it may increase the risk of contamination by extending the area where non-sterile items may come in contact. Keeping hands below waist level (choice B) is also incorrect as it does not prevent contamination effectively. Opening the sterile package away from the body (choice C) is incorrect since it exposes the contents to the nurse's body, which is not sterile.

4. A client is 48 hours post-op from a bowel resection and has not had a bowel movement. The client is complaining of abdominal pain and bloating. What is the nurse’s best action?

• A. Administer a prescribed laxative.
• B. Encourage the client to increase fluid intake.
• C. Auscultate bowel sounds.
• D. Notify the healthcare provider.

Correct answer: C

Rationale: Auscultating bowel sounds is the best initial action in this situation. It helps the nurse assess bowel function before considering interventions like administering a laxative. Abdominal pain and bloating could be indicative of bowel motility issues, and auscultation can provide crucial information. Encouraging increased fluid intake can be beneficial in promoting bowel movement, but assessing bowel sounds is more immediate to evaluate the current status. Notifying the healthcare provider should be reserved for situations where immediate intervention is needed or if the condition worsens after assessment.

5. In what order should the PN implement these steps to provide wound care? (Place in correct order.)

• A. Don procedure gloves
• B. Remove the dressing
• C. Apply prescribed medications to the wound
• D. All of the Above

Correct answer: D

Rationale: The correct answer is 'D - All of the Above.' The PN should first don procedure gloves to maintain aseptic technique, then remove the dressing to assess the wound, and finally apply prescribed medications to the wound. This sequence ensures that non-sterile tasks like donning gloves are done before sterile tasks like applying medications, reducing the risk of wound contamination. Choices A, B, and C are all essential steps in providing effective wound care.

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