Nursing Elites

1. A child is postoperative following a tonsillectomy. Which of the following actions should the nurse take?

• A. Administer analgesics to the child on a routine schedule throughout the day and night.
• B. Offer fluids to the child immediately after surgery.
• C. Allow the child to return to solid foods gradually.
• D. Avoid administering any medication until the child is fully awake.

Correct answer: A

Rationale: Administering analgesics to the child on a routine schedule throughout the day and night is crucial for managing postoperative pain effectively and ensuring the child's comfort. Pain management is a priority in the postoperative period to promote healing and prevent complications. Offering fluids to the child immediately after surgery (Choice B) is essential to prevent dehydration, but pain control takes precedence. Allowing the child to return to solid foods gradually (Choice C) is important, but initially, the child may need to start with clear liquids and progress to soft foods post-tonsillectomy. Avoiding administering any medication until the child is fully awake (Choice D) is not advisable because timely pain relief is essential for the child's comfort and recovery.

2. After completing an assessment and determining that a client has a problem, what should the LPN/LVN do next?

• A. Determine the etiology of the problem.
• B. Prioritize nursing care interventions.
• C. Plan appropriate interventions.
• D. Collaborate with the client to set goals.

Correct answer: A

Rationale: After identifying a problem in a client, the next step for the LPN/LVN is to determine the etiology or cause of the problem. Understanding the root cause of the issue is essential as it guides the development of appropriate interventions. Option B, prioritizing nursing care interventions, is premature without knowing the cause of the problem. Option C, planning appropriate interventions, also relies on knowing the etiology first to ensure the interventions directly address the underlying issue. Collaborating with the client to set goals, as mentioned in option D, is important but typically comes after understanding the cause of the problem to ensure the goals are relevant and effective.

3. What is the rate of delivery in mL/hr if a total volume of 750 mL is infused over a period of 7 hours?

• A. 107 mL/hr.
• B. 107 mL/hr.
• C. 107 mL/hr.
• D. 107 mL/hr.

Correct answer: A

Rationale: The correct rate of delivery is 107 mL/hr. To find the rate of delivery, divide the total volume by the total time: 750 mL / 7 hours = 107 mL/hr. Choice B, C, and D are incorrect as they do not match the correct calculation based on the total volume and time provided.

4. When changing a client's colostomy pouch and noticing peristomal skin irritation, which of the following actions should the nurse take?

• A. Change the pouch as needed based on individual requirements.
• B. Apply the pouch only when the skin barrier is completely dry.
• C. Pat the peristomal skin dry after cleaning.
• D. Ensure the pouch is 0.32 cm (1/8 in) larger than the stoma.

Correct answer: D

Rationale: When a nurse observes peristomal skin irritation while changing a client's colostomy pouch, it is crucial to ensure that the pouch is slightly larger (0.32 cm or 1/8 inch) than the stoma. This extra space helps prevent the pouch from rubbing against the stoma and causing further irritation. Option A is correct because colostomy pouches should be changed based on individual needs, not necessarily every 24 hours. Option B is incorrect because applying the pouch only when the skin barrier is completely dry ensures better adhesion. Option C is incorrect as patting the peristomal skin dry after cleaning is more gentle and less likely to cause irritation compared to rubbing.

5. A nurse is providing care to a 17-year-old client in the post-operative care unit (PACU) after an emergency appendectomy. Which finding is an early indication that the client is experiencing poor oxygenation?

• A. Abnormal breath sounds
• B. Cyanosis of the lips
• C. Increasing pulse rate
• D. Pulse oximeter reading of 92%

Correct answer: C

Rationale: An increasing pulse rate can be an early sign of poor oxygenation as the body tries to compensate. Abnormal breath sounds (choice A) can indicate respiratory issues, but they may not always be an early sign of poor oxygenation. Cyanosis of the lips (choice B) is a late sign of inadequate oxygenation. A pulse oximeter reading of 92% (choice D) indicates mild hypoxemia but may not be considered an early indication of poor oxygenation.

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