Nursing Elites

1. A client who is postoperative and has paralytic ileus is being cared for by a nurse. Which of the following abdominal assessments should the nurse expect?

• A. Absent bowel sounds with distention
• B. Hyperactive bowel sounds
• C. Normal bowel sounds
• D. High-pitched bowel sounds

Correct answer: A

Rationale: In a client with paralytic ileus, absent bowel sounds with distention are expected due to decreased or absent bowel motility. This is a key characteristic of paralytic ileus, where the bowel is unable to contract and move contents along the digestive tract. Hyperactive bowel sounds (choice B) are more indicative of increased peristalsis, which is not typically seen in paralytic ileus. Normal bowel sounds (choice C) may not be present in a client with paralytic ileus. High-pitched bowel sounds (choice D) are not typically associated with paralytic ileus. Therefore, the correct assessment finding in this scenario is absent bowel sounds with distention.

2. The nurse is caring for a 4-year-old 2 hours after tonsillectomy and adenoidectomy. Which of the following assessments must be reported immediately?

• A. Vomiting of dark emesis
• B. Complaints of throat pain
• C. Apical heart rate of 110
• D. Increased restlessness

Correct answer: D

Rationale: Increased restlessness must be reported immediately as it may indicate bleeding or other complications post-tonsillectomy and adenoidectomy. This could be a sign of a developing issue that requires urgent intervention. Vomiting of dark emesis, complaints of throat pain, and an apical heart rate of 110 are important to monitor but do not indicate an immediate need for reporting as compared to the potential seriousness of increased restlessness in this scenario.

3. A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue measuring the client's vital signs every 15 minutes and call him back in 1 hour. From a legal perspective, which of the following actions should the nurse take next?

• A. Document the provider's directive in the medical record
• B. Notify the nursing manager
• C. Consult the facility's risk manager
• D. Complete an incident report

Correct answer: B

Rationale: In this scenario, the nurse is facing a critical situation with a client showing signs of hemorrhagic shock. The surgeon's directive of waiting for an hour without providing immediate intervention poses a risk to the client's well-being. The nurse should prioritize the client's safety and advocate for timely and appropriate care. Notifying the nursing manager is the correct action as it activates the chain of command to ensure that the client receives the necessary care promptly. Documenting the provider's directive, consulting the risk manager, or completing an incident report are not the immediate actions needed to address the client's deteriorating condition and ensure patient safety.

4. The caregiver is teaching parents about the diet for a 4-month-old infant with gastroenteritis and mild dehydration. In addition to oral rehydration fluids, the diet should include

• A. Formula or breast milk
• B. Broth and tea
• C. Rice cereal and apple juice
• D. Gelatin and ginger ale

Correct answer: A

Rationale: The correct answer is A: Formula or breast milk. In infants with gastroenteritis and mild dehydration, it is essential to continue feeding them with formula or breast milk along with oral rehydration fluids to provide adequate nutrition and maintain hydration. Option B, broth and tea, may not provide the necessary nutrients and electrolytes needed for the infant's recovery. Option C, rice cereal and apple juice, can be harsh on the digestive system and may exacerbate diarrhea. Option D, gelatin and ginger ale, do not provide the necessary nutrients and can worsen the condition due to the high sugar content in ginger ale.

5. A healthcare professional is preparing to inject heparin subcutaneously for a client who is postoperative. Which of the following actions should the healthcare professional take?

• A. Use a 25-gauge needle.
• B. Select a site on the client’s abdomen.
• C. Use the Z-track technique to displace the skin on the injection site.
• D. Observe for bleb formation to confirm proper placement.

Correct answer: B

Rationale: For subcutaneous injections like heparin, a 25-27 gauge needle is recommended, making choice A incorrect. The abdomen is a commonly used site for heparin injection due to its consistent absorption and convenience, making choice B the correct answer. The Z-track technique is not necessary for subcutaneous injections, making choice C unnecessary. Observing for bleb formation is not a standard practice for confirming proper placement of subcutaneous heparin, making choice D incorrect. Therefore, the correct action is to select a site on the client's abdomen for the injection.

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