Nursing Elites

1. A nurse is planning care for a client who is postoperative following a bowel resection. Which of the following interventions should the nurse include?

• A. Encourage the client to drink adequate fluids daily.
• B. Administer pain medication as needed.
• C. Instruct the client to splint the incision with a pillow.
• D. Encourage the client to eat a balanced diet.

Correct answer: C

Rationale: The correct intervention for a client post-bowel resection is to instruct the client to splint the incision with a pillow. This technique helps prevent dehiscence, which is the separation of wound edges, and reduces pain when coughing or moving. Splinting supports the incision site, decreasing tension on the wound. Encouraging the client to drink adequate fluids promotes hydration and aids in recovery, but a specific volume like 1,000 mL mentioned in choice A is not essential. Pain medication should be administered as needed for adequate pain control, not necessarily before every meal. Instructing the client to eat a balanced diet, including adequate protein, is crucial for wound healing and overall recovery, rather than limiting protein intake.

2. Which electrolyte imbalance is most concerning in a patient on furosemide?

• A. Hyperkalemia
• B. Hypokalemia
• C. Hyponatremia
• D. Hypercalcemia

Correct answer: B

Rationale: The correct answer is Hypokalemia. Furosemide is a loop diuretic that can lead to potassium depletion by increasing its excretion in the urine. Hypokalemia is a common and concerning side effect of furosemide therapy. Hyperkalemia (Choice A) is less likely as furosemide tends to lower potassium levels. Hyponatremia (Choice C) is more commonly seen with thiazide diuretics. Hypercalcemia (Choice D) is not directly associated with furosemide use.

3. A nurse in a mental health facility is caring for a client who is angry and throwing objects at staff members. Which of the following actions should the nurse take?

• A. Ask the client to identify what made them angry.
• B. Instruct the client to calm down.
• C. Place the client in seclusion.
• D. Encourage the client to attend group therapy.

Correct answer: C

Rationale: During a situation where a client is exhibiting violent behavior like throwing objects and posing a risk to themselves and others, the immediate priority is to ensure the safety of all involved. Placing the client in seclusion is a necessary intervention to prevent harm and allow for de-escalation. Asking the client to identify the trigger or instructing them to calm down may not be effective or safe in this escalated state. Encouraging the client to attend group therapy is not suitable when they are in an agitated and aggressive state that requires immediate intervention.

4. Which lab value should be monitored in patients receiving heparin therapy?

• A. Monitor aPTT
• B. Monitor INR
• C. Monitor platelet count
• D. Monitor sodium levels

Correct answer: A

Rationale: The correct answer is to monitor aPTT in patients receiving heparin therapy. Activated Partial Thromboplastin Time (aPTT) is crucial to assess the therapeutic effectiveness of heparin and to prevent bleeding complications. Monitoring INR (Choice B) is more relevant for patients on warfarin therapy, not heparin. Platelet count (Choice C) monitoring is essential for detecting heparin-induced thrombocytopenia rather than assessing heparin therapy itself. Monitoring sodium levels (Choice D) is not directly related to heparin therapy monitoring.

5. A nurse is caring for a client who has a new diagnosis of hypothyroidism. Which of the following findings should the nurse expect?

• A. Weight gain.
• B. Bradycardia.
• C. Tachycardia.
• D. Heat intolerance.

Correct answer: B

Rationale: The correct answer is B: Bradycardia. Bradycardia, or a slow heart rate, is a common finding in clients with hypothyroidism because of the decreased metabolic rate associated with this condition. Weight gain is also a common symptom of hypothyroidism due to the metabolic changes, making choice A incorrect. Tachycardia, or a rapid heart rate, is typically seen in hyperthyroidism, not hypothyroidism, so choice C is incorrect. Heat intolerance is more commonly associated with hyperthyroidism rather than hypothyroidism, making choice D incorrect.

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