Nursing Elites

1. A client is about to undergo emergency abdominal surgery for appendicitis. A healthcare professional is demonstrating postoperative deep breathing and coughing exercises to the client. The healthcare professional realizes the client may be unprepared to learn if the client:

• A. Is not feeling well
• B. Reports severe pain
• C. Has low blood pressure
• D. Is anxious

Correct answer: B

Rationale: Severe pain can be a significant distraction and impediment to the learning process. When a client is experiencing severe pain, their focus and attention are primarily directed towards managing the pain, making it difficult for them to absorb and retain new information effectively. Options A, C, and D, although important considerations in a healthcare setting, do not directly impact the client’s ability to learn in the same way that severe pain does. Not feeling well, low blood pressure, and anxiety are all factors that can be addressed or managed to facilitate learning, unlike severe pain which can significantly hinder the learning process.

2. When transferring a postoperative client from the PACU following abdominal surgery, what action should the nurse take to move the client from the stretcher to the bed?

• A. Lock the wheels on both the bed and stretcher
• B. Adjust the bed to a low position
• C. Ask the client to assist in the transfer
• D. Use a transfer sheet without locking the wheels

Correct answer: A

Rationale: Locking the wheels on both the bed and stretcher is crucial for ensuring stability during the transfer process. This action is essential to prevent unexpected movement of the bed or stretcher, reducing the risk of injury to the client and facilitating a safe transfer. Adjusting the bed to a low position is important for the client's comfort and safety but does not directly address the immediate need for stability during the transfer. Asking the client to assist in the transfer may not be feasible immediately postoperatively, depending on their condition and the type of surgery they underwent. Using a transfer sheet without locking the wheels can introduce potential safety hazards as the bed or stretcher may move during the transfer, undermining the stability needed for a safe and effective transfer.

3. A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit, and her ankles are edematous. Which of the following findings by the nurse is another clinical manifestation of fluid volume excess?

• A. Bounding pulse
• B. Decreased blood pressure
• C. Dry mucous membranes
• D. Weak pulse

Correct answer: A

Rationale: A bounding pulse is indicative of fluid volume excess. In this case, the client's weight gain and edematous ankles already suggest fluid volume overload. A bounding pulse occurs due to increased blood volume and pressure. Choices B, C, and D are not indicative of fluid volume excess. Decreased blood pressure, dry mucous membranes, and weak pulse are more commonly associated with conditions such as dehydration or hypovolemia, where there is a decrease in fluid volume rather than an excess.

4. A healthcare provider is receiving a prescription for a client who is experiencing dysphagia following a stroke. Which of the following prescriptions should the healthcare provider clarify?

• A. Dietitian consult
• B. Speech therapy referral
• C. Oral suction at the bedside
• D. Clear liquids

Correct answer: D

Rationale: The correct answer is D: 'Clear liquids.' Clients with dysphagia following a stroke are at high risk of aspiration, and clear liquids have a higher risk of aspiration compared to thickened liquids. Therefore, the healthcare provider should clarify the prescription for clear liquids and consider recommending thickened liquids instead to reduce the risk of aspiration. Choice A, 'Dietitian consult,' is essential to ensure the client receives appropriate nutrition tailored to their condition. Choice B, 'Speech therapy referral,' is crucial for dysphagia management and rehabilitation. Choice C, 'Oral suction at the bedside,' is a standard intervention to maintain airway patency and is not contraindicated in clients with dysphagia.

5. The healthcare provider is planning care for a 3-month-old infant immediately postoperative following placement of a ventriculoperitoneal shunt for hydrocephalus. The healthcare provider needs to

• A. Assess for abdominal distention
• B. Maintain the infant in an upright position
• C. Begin feeding formula when the infant is alert
• D. Pump the shunt to assess for proper function

Correct answer: A

Rationale: Assessing for abdominal distention is crucial in this situation as it can indicate a complication with the shunt or fluid accumulation. Abdominal distention may suggest an issue with the shunt placement, such as obstruction or overdrainage, which requires immediate intervention. Maintaining the infant in an upright position (Choice B) is not the priority immediately postoperatively following a ventriculoperitoneal shunt placement. Beginning formula feedings when the infant is alert (Choice C) may be appropriate but is not the priority over assessing for abdominal distention. Pumping the shunt to assess for proper function (Choice D) is not a recommended nursing intervention postoperatively and should be done by a qualified healthcare provider.

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