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. A nurse is caring for a client who is receiving enteral feedings through an NG tube. Which of the following actions should the nurse take to prevent aspiration?

• A. Flush the NG tube with 0.9% sodium chloride before feedings.
• B. Place the client in a high Fowler's position during feedings.
• C. Administer the feedings over 30 minutes.
• D. Warm the formula before administering it.

Correct answer: B

Rationale: The correct answer is to place the client in a high Fowler's position during enteral feedings. This position helps prevent aspiration by promoting the downward flow of the feeding and reducing the risk of regurgitation into the lungs. Choice A is incorrect because flushing the NG tube with 0.9% sodium chloride before feedings is not directly related to preventing aspiration. Choice C is incorrect because the rate of administration does not directly impact the risk of aspiration. Choice D is incorrect because warming the formula does not specifically address the prevention of aspiration during enteral feedings.

3. A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets and has a respiratory rate of 10/min. After securing the client's airway and initiating an IV, which of the following actions should the nurse do next?

• A. Monitor the client's IV site for thrombophlebitis
• B. Administer flumazenil to the client
• C. Evaluate the client for further suicidal behavior
• D. Initiate seizure precautions for the client

Correct answer: B

Rationale: Administering flumazenil is the priority to reverse the effects of diazepam overdose. Monitoring the IV site for thrombophlebitis (choice A) is important but not the next immediate action. Evaluating the client for further suicidal behavior (choice C) is important but not the priority at this moment. Initiating seizure precautions (choice D) is not the priority action in this scenario.

4. A nurse is caring for a client who is receiving morphine for pain management. Which of the following findings indicates the client is experiencing an adverse effect of the medication?

• A. Diaphoresis
• B. Hypotension
• C. Urinary retention
• D. Tachycardia

Correct answer: C

Rationale: Urinary retention is an adverse effect of morphine, as it can lead to the relaxation of the detrusor muscle and sphincter constriction in the bladder. Diaphoresis, hypotension, and tachycardia are common side effects of morphine due to its vasodilatory effects and impact on the autonomic nervous system. Diaphoresis is excessive sweating, which can be a normal response to pain or fever. Hypotension and tachycardia can occur due to morphine's vasodilatory effects and its impact on the cardiovascular system. Therefore, the presence of urinary retention would indicate the need for further assessment and intervention.

5. A healthcare professional is reviewing a client's admission laboratory results. Which of the following findings requires further evaluation?

• A. Sodium 138
• B. Creatinine 1.8
• C. Hemoglobin 15
• D. Potassium 4.2

Correct answer: B

Rationale: The correct answer is B. An elevated creatinine level, such as 1.8, suggests potential kidney dysfunction, requiring further assessment. Sodium level within normal limits (135-145 mEq/L), hemoglobin level of 15 g/dL, and potassium level of 4.2 mEq/L are all within normal ranges and do not indicate immediate concerns. Therefore, they do not require further evaluation at this time.

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