Nursing Elites

1. A patient is 1 hour postoperative following an open reduction internal fixation of the left tibia. Which of the following actions should the nurse take?

• A. Assess neurovascular status of the extremities every 4 hours
• B. Monitor the patient's pain level every 8 hours
• C. Assist the patient to the bathroom every 2 hours
• D. Keep the patient's left leg elevated on two pillows

Correct answer: A

Rationale: The correct action for the nurse to take 1 hour postoperative following an open reduction internal fixation of the left tibia is to assess neurovascular status of the extremities every 4 hours. This frequent assessment is crucial to monitor for any signs of complications such as impaired circulation or nerve damage. Monitoring every 4 hours allows for early detection of any issues, enabling timely intervention and prevention of potential complications. Monitoring the patient's pain level every 8 hours (choice B) is not as immediate or essential for postoperative care. Assisting the patient to the bathroom every 2 hours (choice C) may not be necessary if the patient is not ambulatory yet. Keeping the patient's left leg elevated on two pillows (choice D) can be beneficial but is not the priority in the immediate postoperative period compared to assessing neurovascular status.

2. The healthcare provider is assessing abdominal girth for a pediatric client who presents with abdominal distension. Which nursing action is appropriate?

• A. Measuring the girth just below the umbilicus
• B. Measuring the girth just below the sternum
• C. Measuring the girth just above the pubic bone
• D. Measuring the girth around the largest portion of the abdomen

Correct answer: D

Rationale: Measuring the girth around the largest portion of the abdomen ensures accurate assessment and tracking of abdominal distension. This method provides a more comprehensive measurement and helps healthcare providers monitor changes effectively.

3. Which type of play involves actions such as looking and touching the mother's face, putting hands in one's mouth, and responding to familiar people?

• A. Exploratory
• B. Functional or relational
• C. Pretend
• D. Symbolic or imaginary

Correct answer: A

Rationale: Exploratory play is characterized by exploring sensory experiences and learning about the environment. In this type of play, infants engage in activities like looking, touching, and responding to familiar stimuli to understand the world around them.

4. A caregiver is learning about administering digoxin to a toddler. Which statement by the caregiver indicates an understanding of the teaching?

• A. I will mix the medication with a small amount of juice.
• B. I will give the medication with meals.
• C. I will give a second dose if my child vomits.
• D. I will give my child water after giving the medication.

Correct answer: D

Rationale: The correct statement is D because giving the child water after administering digoxin helps ensure the medication is swallowed properly. Mixing the medication with juice (choice A) may affect its absorption. Giving the medication with meals (choice B) may interfere with its effectiveness. Administering a second dose if the child vomits (choice C) is not recommended as it may lead to an overdose.

5. Following a child's return from exploratory surgery due to a gunshot wound to the abdomen, which nursing intervention should be excluded from the plan of care?

• A. Immediate initiation of oral feedings
• B. Assessment of the surgical site
• C. Administration of opioid narcotics for pain management
• D. Visitation at the bedside

Correct answer: A

Rationale: Immediate initiation of oral feedings should be excluded from the plan of care post-abdominal surgery due to the risk of bowel complications like paralytic ileus or anastomotic leak. Starting oral feedings immediately can increase these risks and hinder healing. It is crucial to wait until bowel function returns and the patient shows signs of tolerance before introducing oral feedings. Assessment of the surgical site is necessary to monitor for any signs of infection or complications. Administration of opioid narcotics for pain management is essential for ensuring the patient's comfort post-surgery. Visitation at the bedside provides emotional support and can aid in the patient's recovery. Therefore, the correct answer is to exclude immediate initiation of oral feedings.

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