Nursing Elites

1. A client with bladder cancer had surgical placement of a ureteroileostomy (ileal conduit) yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider immediately?

• A. red and edematous stoma appearance
• B. liquid brown drainage from stoma
• C. stoma output of 40ml in the last hour
• D. mucous strings floating in the drainage

Correct answer: C

Rationale: Stoma output of only 40ml in the last hour may indicate a problem, such as dehydration or blockage, and should be reported immediately. A red and edematous stoma appearance could be due to inflammation, which is expected in the early postoperative period. Liquid brown drainage from the stoma is a normal finding. Mucous strings floating in the drainage are also a common occurrence postoperatively and do not typically require immediate reporting.

2. The nurse is teaching the parent of a child newly diagnosed with a latex allergy. Which information by the parents indicates a need for further teaching?

• A. Rubber-free toys, such as wooden building blocks, are good choices for the child.
• B. Only foil balloons will be used for the child's birthday party.
• C. A diet of healthy fruits, such as bananas and kiwis, is best for the child.
• D. An epinephrine auto-injector will be on hand to treat allergic reactions.

Correct answer: C

Rationale: The correct answer is C. Bananas and kiwis are foods that can cross-react with latex allergy, indicating that the parents need further teaching on managing latex allergies. Choices A, B, and D are correct as rubber-free toys, using foil balloons, and having an epinephrine auto-injector are appropriate measures to prevent and manage allergic reactions in a child with a latex allergy.

3. What is the first action the nurse should take when a patient complains of acute chest pain and dyspnea soon after insertion of a centrally inserted IV catheter?

• A. Notify the health care provider.
• B. Offer reassurance to the patient.
• C. Auscultate the patient’s breath sounds
• D. Give the prescribed PRN morphine sulfate IV

Correct answer: C

Rationale: The correct first action for the nurse to take when a patient complains of acute chest pain and dyspnea after the insertion of a centrally inserted IV catheter is to auscultate the patient's breath sounds. This is important to assess for any potential complications such as embolism or pneumothorax, which can present with such symptoms. Auscultation can provide immediate information on the patient's respiratory status and guide further interventions. Notifying the health care provider, offering reassurance, or administering morphine should only be considered after assessing the patient's condition through auscultation.

4. An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation?

• A. Pallor
• B. Edema
• C. Confusion
• D. Restlessness

Correct answer: B

Rationale: The correct answer is B: Edema. The normal range for total protein is 6.4 to 8.3 g/dL. Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not associated with low serum protein levels. Pallor is more commonly seen in anemia, confusion and restlessness may be related to other issues like electrolyte imbalances or neurological conditions.

5. A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question?

• A. Infuse 5% dextrose in water at 125 mL/hr.
• B. Administer IV morphine sulfate 4 mg every 2 hours PRN.
• C. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea.
• D. Administer 3% saline if serum sodium decreases to less than 128 mEq/L.

Correct answer: A

Rationale: The nurse should question the prescription to infuse 5% dextrose in water at 125 mL/hr because the patient's gastric suction has been depleting electrolytes, leading to hyponatremia. Therefore, the IV solution should include electrolyte replacement. Solutions like lactated Ringer’s solution would usually be ordered. The other choices (B, C, and D) are appropriate for a postoperative patient with gastric suction, addressing pain management, nausea control, and correcting hyponatremia if it drops below a certain level.

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