Nursing Elites

1. A client is 48 hours postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication?

• A. Impaired peristalsis of the intestines
• B. Infection at the surgical site
• C. Fluid overload
• D. Inadequate pain management

Correct answer: A

Rationale: Gas pains in the periumbilical area postoperatively are often caused by impaired peristalsis and bowel function. Following abdominal surgery, it is common for peristalsis to be reduced due to surgical manipulation and anesthesia effects. This reduction in peristalsis can lead to the accumulation of gas in the intestines, resulting in gas pains. Infection at the surgical site (Choice B) would present with localized signs of infection such as redness, swelling, warmth, and drainage, rather than diffuse gas pains. Fluid overload (Choice C) would manifest with symptoms such as edema, increased blood pressure, and respiratory distress, not gas pains. Inadequate pain management (Choice D) may lead to increased discomfort, but it is not the primary cause of gas pains in the periumbilical area following a small bowel resection.

2. A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the bedrail onto the floor. Which of the following statements should the nurse document about this incident?

• A. ''Incident report completed.''
• B. ''Client climbed over the bedrails.''
• C. ''Client found lying on the floor.''
• D. ''Client was trying to get out of bed.''

Correct answer: C

Rationale: The correct answer is C: ''Client found lying on the floor.'' In this situation, the nurse should document factual, objective information without making assumptions. Stating that the client was found lying on the floor directly reflects what was observed. Choice A, ''Incident report completed,'' is not a statement about the incident itself and does not provide relevant information. Choice B, ''Client climbed over the bedrails,'' introduces unnecessary speculation and assumption which should be avoided when documenting incidents. Choice D, ''Client was trying to get out of bed,'' focuses on the client's behavior rather than the objective observation of the client's position when found.

3. A healthcare professional is preparing to administer 750 mL of 0.9% sodium chloride IV to infuse over 7 hours. The healthcare professional should set the pump to deliver how many mL/hr?

• A. 107 mL/hr
• B. 75 mL/hr
• C. 90 mL/hr
• D. 60 mL/hr

Correct answer: A

Rationale: To calculate the mL/hr rate for the infusion, divide the total volume (750 mL) by the total time (7 hours). 750 mL ÷ 7 hours = 107 mL/hr. This means that the pump should be set to deliver approximately 107 mL/hr. Choice B (75 mL/hr) is incorrect because it does not reflect the correct calculation. Choice C (90 mL/hr) is incorrect as it does not align with the accurate calculation. Choice D (60 mL/hr) is incorrect as it does not match the correct mL/hr rate obtained through the calculation.

4. A client is being treated for diabetic ketoacidosis (DKA). Which laboratory value would be most concerning?

• A. Blood glucose of 350 mg/dL
• B. Serum bicarbonate of 18 mEq/L
• C. Arterial pH of 7.20
• D. Serum potassium of 5.5 mEq/L

Correct answer: C

Rationale: In a client with diabetic ketoacidosis (DKA), the most concerning laboratory value is an arterial pH of 7.20. An arterial pH of 7.20 indicates severe acidosis, which is a critical condition requiring immediate intervention. This pH level reflects a significant imbalance in the body's acid-base status, potentially leading to serious complications. High blood glucose levels (choice A) are expected in DKA but do not directly indicate the severity of acidosis. A serum bicarbonate level of 18 mEq/L (choice B) is low but not as immediately critical as a pH of 7.20. Serum potassium of 5.5 mEq/L (choice D) is elevated, which can occur in DKA due to insulin deficiency, but it is not the most concerning value in this scenario.

5. A client with a history of coronary artery disease is experiencing chest pain. What is the priority action for the LPN/LVN to take?

• A. Administer nitroglycerin sublingually.
• B. Obtain a 12-lead ECG.
• C. Measure the client's vital signs.
• D. Administer oxygen via nasal cannula.

Correct answer: A

Rationale: The correct answer is to administer nitroglycerin sublingually. Administering nitroglycerin sublingually is the priority action for a client with chest pain and a history of coronary artery disease. Nitroglycerin helps dilate the coronary arteries, improving blood flow to the heart muscle and providing rapid relief of chest pain. Obtaining a 12-lead ECG, measuring vital signs, and administering oxygen are important actions but should follow the administration of nitroglycerin in the management of chest pain in a client with coronary artery disease.

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