Nursing Elites

1. A client who has just had a mastectomy has a closed wound suction device (hemovac) in place. Which nursing action will ensure proper operation of the device?

• A. Collapsing the device whenever it is 1/2 to 2/3 full of air.
• B. Emptying the device every 4 hours.
• C. Replacing the device every 24 hours.
• D. Keeping the device above the level of the surgical site.

Correct answer: A

Rationale: Collapsing the device when it is 1/2 to 2/3 full of air is the correct nursing action to ensure proper operation of a closed wound suction device (hemovac). This action maintains negative pressure, which is essential for proper suction and drainage of the wound. Emptying the device every 4 hours (Choice B) is not necessary as the focus should be on collapsing it appropriately. Replacing the device every 24 hours (Choice C) is not a standard practice unless indicated by the healthcare provider. Keeping the device above the level of the surgical site (Choice D) is not necessary for the device's proper operation; collapsing it to maintain negative pressure is the key action.

2. A client who is postoperative has paralytic ileus. Which of the following abdominal assessments should the nurse expect?

• A. Absent bowel sounds with distention
• B. Hyperactive bowel sounds with pain
• C. Normal bowel sounds with cramping
• D. Diminished bowel sounds with tenderness

Correct answer: A

Rationale: Paralytic ileus is a condition where there is a temporary paralysis of the bowel, leading to absent bowel sounds and abdominal distention. This occurs because the bowel is not functioning properly to propel contents, resulting in a lack of bowel sounds. Absent bowel sounds with distention are typical findings in paralytic ileus. Hyperactive bowel sounds with pain are more indicative of increased motility and are not expected in paralytic ileus. Normal bowel sounds with cramping may be seen in other conditions, such as gastroenteritis. Diminished bowel sounds with tenderness are not typical findings in paralytic ileus.

3. A nurse receives a prescription for an antibiotic for a client with cellulitis. The nurse checks the client’s medical record, discovers the client's allergy to the antibiotic, and calls the provider for a different prescription. Which of the following critical thinking attitudes did the nurse demonstrate?

• A. Fairness
• B. Responsibility
• C. Risk-taking
• D. Creativity

Correct answer: B

Rationale: The nurse demonstrated responsibility by recognizing the potential harm of administering an antibiotic the client is allergic to and taking the necessary steps to ensure the client's safety. Choice A, 'Fairness,' is not applicable in this scenario as it does not involve treating individuals equitably. Choice C, 'Risk-taking,' is incorrect as the nurse's actions aimed to minimize risks rather than taking them. Choice D, 'Creativity,' is not the best fit as the nurse's actions focused on following established protocols and ensuring patient safety rather than thinking innovatively.

4. When is a depressed client at highest risk for attempting suicide?

• A. Immediately after admission, during one-to-one observation
• B. 7 to 14 days after initiation of antidepressant medication and psychotherapy
• C. Following an angry outburst with family
• D. When the client is removed from the security room

Correct answer: B

Rationale: Depressed clients are at the highest risk of attempting suicide 7 to 14 days after starting antidepressant medication and psychotherapy. During this time, they may start to regain energy but still feel hopeless, which can increase the risk of suicidal ideation and behavior. Choices A, C, and D are incorrect because immediate post-admission, after an angry outburst with family, or when removed from a security room are not specific periods known to be associated with the highest risk of suicide in depressed clients.

5. A client with a history of seizures is prescribed phenytoin (Dilantin). What side effect should the healthcare provider report immediately?

• A. Increased appetite
• B. Dry mouth
• C. Nausea and vomiting
• D. Gingival hyperplasia

Correct answer: D

Rationale: Gingival hyperplasia is a significant side effect associated with phenytoin therapy. It is characterized by an overgrowth of gum tissue, which can lead to issues such as difficulty in speaking, eating, and maintaining proper oral hygiene. This condition can progress rapidly and may require immediate intervention by the healthcare provider to prevent further complications. Increased appetite, dry mouth, and nausea/vomiting are common side effects of various medications, but they are not as urgent or serious as gingival hyperplasia in a client taking phenytoin.

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