Nursing Elites

1. 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.

2. A nurse is collecting data from a client who is reporting pain despite taking analgesics. Which of the following actions should the nurse take to determine the intensity of the client’s pain?

• A. Ask the client what precipitates the pain.
• B. Question the client about the location of the pain.
• C. Offer the client a pain scale to measure their pain.
• D. Use open-ended questions to identify the client’s pain sensations.

Correct answer: C

Rationale: Offering the client a pain scale is the most appropriate action to determine the intensity of the client’s pain. Pain scales help quantify the intensity of pain, providing a standardized way to assess and compare pain levels. Asking about precipitating factors (choice A) may help identify triggers but does not directly measure pain intensity. Questioning about the location of pain (choice B) helps with localization but not with quantifying intensity. Using open-ended questions (choice D) may provide insights into the quality and experience of pain but does not provide a standardized measure of intensity.

3. A client's readiness to learn about insulin administration is being assessed by a nurse. Which of the following statements should the nurse identify as an indication that the client is ready to learn?

• A. ''I can concentrate best in the morning.''
• B. ''It is difficult to read the instructions because my glasses are at home.''
• C. ''I'm wondering why I need to learn this.''
• D. ''You will have to talk to my wife about this.''

Correct answer: A

Rationale: Choice A is the correct answer because the client's statement about the best time to concentrate indicates readiness for learning. This statement shows an awareness and interest in learning. Choice B is incorrect as it indicates a barrier to learning due to not having glasses. Choice C is incorrect as it shows a lack of understanding or motivation for learning. Choice D is incorrect as it suggests a lack of personal involvement or responsibility in the learning process since the client is deflecting the responsibility to someone else.

4. A client who has been experiencing frequent tonic-clonic seizures is being admitted by a nurse. Which of the following actions should the nurse include in the client's plan of care?

• A. Wrap blankets around all four sides of the bed.
• B. Place the client in a padded room.
• C. Maintain the bed in the lowest position.
• D. Ensure the client has a soft mattress.

Correct answer: C

Rationale: Maintaining the bed in the lowest position is crucial in reducing the risk of injury during tonic-clonic seizures. This action helps prevent falls and minimizes potential harm to the client. Wrapping blankets around all four sides of the bed (Choice A) may restrict movement during a seizure and increase the risk of injury. Placing the client in a padded room (Choice B) is not a practical approach in a healthcare setting and may not be feasible. Ensuring the client has a soft mattress (Choice D) alone does not address the safety concerns during seizures, unlike keeping the bed in the lowest position.

5. A client is 24 hours postoperative following an inguinal hernia repair. The client is tolerating clear liquids well, has active bowel sounds, and is expressing a desire for “real food.” The nurse tells the client, “I will call the surgeon and ask for a change in diet.” The surgeon hears the nurse’s report and prescribes a full liquid diet. The nurse used which of the following levels of critical thinking?

• A. Basic
• B. Commitment
• C. Complex
• D. Integrity

Correct answer: C

Rationale: The nurse demonstrated complex critical thinking by assessing the client's condition, evaluating the need for a change, and making a recommendation to the surgeon. In this scenario, the nurse went beyond simply following instructions or making routine decisions (basic critical thinking). There was a depth of analysis and decision-making involved, showing a higher level of critical thinking than basic or commitment levels. Integrity is about adherence to ethical principles and honesty, not directly related to the critical thinking process.

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