Nursing Elites

1. A client who is post-operative from a bowel resection is experiencing abdominal distention and pain. The nurse notices the client has not passed gas or had a bowel movement. What should the nurse assess first?

• A. The client's bowel sounds.
• B. The client's fluid intake.
• C. The client's pain level.
• D. The client's surgical incision.

Correct answer: A

Rationale: Assessing bowel sounds is crucial in this situation as it helps determine if the client's gastrointestinal tract is functioning properly. Absent or hypoactive bowel sounds can indicate an ileus, a common post-operative complication. Assessing fluid intake (Choice B) is important but should come after assessing bowel sounds. Pain assessment (Choice C) is essential but addressing the physiological issue should take precedence. Checking the surgical incision (Choice D) is relevant but not the priority when the client is experiencing abdominal distention and potential gastrointestinal complications.

2. A 50-year-old female is in the hospital with peripheral artery disease. In the nursing care plan, the nurse lists the following nursing diagnosis: Ineffective tissue perfusion: peripheral related to venous stasis. Which of the following would not be an appropriate nursing action to list in the implementation of this diagnosis?

• A. Keep the client's extremities cold
• B. Check for strength and symmetry of peripheral pulses
• C. Keep the client's legs elevated
• D. Monitor for any constrictions, such as clothes or covers that are too tight around the legs

Correct answer: A

Rationale: Keeping the client’s extremities cold would worsen perfusion issues and is not recommended. In peripheral artery disease, maintaining warmth is crucial to promote vasodilation and improve blood flow. Checking peripheral pulses for strength and symmetry, keeping the client's legs elevated to reduce venous stasis, and monitoring for constrictions that may impair circulation are appropriate nursing actions to enhance tissue perfusion in this case. Thus, option A is incorrect as it would hinder perfusion in the affected extremities.

3. The home health nurse suspects elder abuse after observing fresh lacerations on the arms and legs of an older adult male client who lives with his daughter. Which action is most important for the nurse to take?

• A. Document the lacerations in the client's record
• B. Report findings to the supervisor for referral to adult protective services
• C. Ask the daughter who has been taking care of the client on a daily basis
• D. Apply dry dressings after cleansing the wounds

Correct answer: B

Rationale: In cases where elder abuse is suspected, the most critical action for the nurse to take is to report the findings to the supervisor for referral to adult protective services. This step is essential to protect the client from further harm and ensure their safety. Documenting the lacerations, as suggested in choice A, is important but not as urgent as ensuring immediate intervention by reporting the abuse. Asking the daughter for information, as in choice C, may not be effective if she is the abuser. Applying dressings, as in choice D, is a lower priority compared to taking action to address the suspected abuse.

4. A child with glomerulonephritis is admitted in the acute edematous phase. Based on this diagnosis, which nursing intervention should the nurse plan to include in the child's plan of care?

• A. Recommend parents bring favorite snacks
• B. Encourage ambulation daily to the playroom
• C. Measure blood pressure every 4 to 6 hours
• D. Offer a selection of fresh fruit for each meal

Correct answer: C

Rationale: The correct answer is to measure blood pressure every 4 to 6 hours. Monitoring blood pressure frequently is crucial in managing glomerulonephritis, as hypertension is a common complication during the acute edematous phase. Choice A is incorrect as it does not address the specific needs of a child with glomerulonephritis. Choice B is incorrect as excessive activity may not be suitable during the acute phase, as rest and monitoring are more important. Choice D is incorrect as the focus should be on monitoring vital signs rather than meal options.

5. Thirty minutes after receiving IV morphine, a postoperative client continues to rate pain as 7 on a 10-point scale. Which action should the PN implement first?

• A. Call healthcare provider to request a different analgesic
• B. Determine when morphine can be given again
• C. Implement complementary pain relief methods
• D. Observe dressing to determine the presence of bleeding

Correct answer: C

Rationale: The most appropriate action for the PN to implement first is to implement complementary pain relief methods. This includes repositioning the client, applying heat or cold packs, or using relaxation techniques. These strategies can provide additional pain relief before the next dose of medication is due or before seeking further instructions from the healthcare provider. Calling the healthcare provider immediately to request a different analgesic (Choice A) may not be necessary at this moment since other non-pharmacological methods can be attempted first. Determining when morphine can be given again (Choice B) is important but addressing the client's immediate pain relief takes precedence. Observing the dressing for bleeding (Choice D) is important but not the first priority when the client is experiencing unrelieved pain.

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