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. Which action is most important for maintaining sterility when donning sterile gloves?

• A. Maintain thumbs at a ninety-degree angle.
• B. Hold hands with fingers pointing downward while gloving.
• C. Keep gloved hands above the elbows.
• D. Put the glove on the dominant hand first.

Correct answer: C

Rationale: The most crucial action for maintaining sterility when donning sterile gloves is to keep gloved hands above the elbows. This practice is essential to prevent potential contamination and maintain a sterile field. Choices A, maintaining thumbs at a ninety-degree angle, and B, holding hands with fingers pointing downward while gloving, are not as critical as keeping hands above the elbows for maintaining sterility. Choice D, putting the glove on the dominant hand first, is not as important as ensuring that gloved hands are kept above the elbows to maintain sterility.

3. The nurse is caring for a client with a tracheostomy who is unable to clear secretions by coughing. What is the most appropriate action for the nurse to take?

• A. Encourage the client to take deep breaths.
• B. Provide humidified oxygen via tracheostomy collar.
• C. Suction the tracheostomy tube as needed.
• D. Change the tracheostomy dressing daily.

Correct answer: C

Rationale: Suctioning the tracheostomy tube as needed is the most appropriate action in this scenario. When a client with a tracheostomy is unable to clear secretions by coughing, suctioning helps remove the excess secretions from the airway, ensuring proper breathing. Encouraging deep breaths (Choice A) may not effectively address the immediate need to clear secretions. Providing humidified oxygen (Choice B) can help with oxygenation but does not directly address the issue of clearing secretions. Changing the tracheostomy dressing daily (Choice D) is important for maintaining cleanliness but is not the priority when the client is unable to clear secretions.

4. A client with hypertension is prescribed a low-sodium diet. Which food should the LPN/LVN recommend the client avoid?

• A. Fresh fruits
• B. Grilled chicken
• C. Whole grain bread
• D. Canned soup

Correct answer: D

Rationale: The correct answer is D, canned soup. Canned soup is often high in sodium, which contradicts the low-sodium diet prescribed for hypertension. Fresh fruits (A) are generally low in sodium and are a healthy choice. Grilled chicken (B) is a lean protein option that is suitable for a low-sodium diet. Whole grain bread (C) is also a good choice as it is not typically high in sodium. Therefore, the LPN/LVN should recommend avoiding canned soup to adhere to the low-sodium dietary restrictions.

5. A client scheduled for a hysterectomy has not yet signed the operative consent form. When the nurse approaches the client and asks that she review and sign the form, the client says she no longer wants to have the surgery. At this time, which action should the nurse take?

• A. Ask the client why she has changed her mind
• B. Proceed with the surgery
• C. Notify the surgeon immediately
• D. Document the client’s decision

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to ask the client why she has changed her mind. By understanding the client's reasons for refusal, the nurse can address any concerns, provide further information, and ensure that the client's decision is respected. Proceeding with the surgery without clarifying the client's decision or notifying the surgeon immediately would not be appropriate. Documenting the client's decision is important, but it should be done after understanding the rationale behind the decision.

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