Nursing Elites

1. A nurse is planning care for a school-age child who is 4 hours postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care?

• A. Offer small amounts of clear liquids 6 hours following surgery.
• B. Give cromolyn nebulizer solution every 6 hours.
• C. Apply a warm compress to the operative site every 4 hours.
• D. Administer analgesics on a scheduled basis for the first 24 hours.

Correct answer: D

Rationale: Administering analgesics on a scheduled basis for the first 24 hours is crucial in managing postoperative pain for the child. This helps control pain levels effectively, promoting comfort and aiding in the recovery process. Offering small amounts of clear liquids 6 hours following surgery may not be appropriate as the child may need time to recover from anesthesia. Giving cromolyn nebulizer solution every 6 hours is not indicated for postoperative care following appendicitis surgery. Applying a warm compress every 4 hours to the operative site may not be recommended as it can potentially interfere with the surgical wound healing process.

2. A nurse is planning care for a client who has a new diagnosis of heart failure. Which of the following interventions should the nurse include in the plan of care?

• A. Limit the client's fluid intake to 1,500 mL per day.
• B. Encourage the client to walk every 2 hours.
• C. Monitor the client's weight daily.
• D. Administer oxygen via nasal cannula at 2 L/min.

Correct answer: C

Rationale: The correct intervention the nurse should include in the plan of care for a client with heart failure is to monitor the client's weight daily. Daily weight monitoring is essential to assess fluid balance and detect any signs of worsening heart failure. Limiting fluid intake to 1,500 mL per day (Choice A) may be appropriate in some cases, but it is not the initial priority for this client. Encouraging the client to walk every 2 hours (Choice B) is generally beneficial for mobility but may not be directly related to managing heart failure. Administering oxygen via nasal cannula at 2 L/min (Choice D) is a supportive measure for hypoxia but does not directly address heart failure management.

3. A nurse is teaching a client who has a new prescription for fluoxetine. Which of the following statements should the nurse include?

• A. "You should expect to feel an improvement in your symptoms within 1 week."
• B. "You may experience weight gain while taking this medication."
• C. "You should take this medication in the morning to prevent insomnia."
• D. "You should stop taking this medication if you experience dry mouth."

Correct answer: B

Rationale: The correct statement the nurse should include is that the client may experience weight gain while taking fluoxetine. Weight gain is a common side effect of fluoxetine, and patients should be informed about this potential issue. Stating that the client should expect improvement in symptoms within 1 week (Choice A) is incorrect as fluoxetine may take a few weeks to have a noticeable effect. Taking the medication in the morning to prevent insomnia (Choice C) is not necessary since fluoxetine can be taken at any time of the day. Instructing the client to stop taking the medication if experiencing dry mouth (Choice D) is misleading, as dry mouth is a common but usually not serious side effect of fluoxetine.

4. A nurse is caring for a client who has a prescription for digoxin. Which of the following laboratory values should the nurse monitor to identify an adverse effect of this medication?

• A. Potassium 3.5 mEq/L
• B. Sodium 140 mEq/L
• C. Calcium 9.5 mg/dL
• D. Magnesium 2.0 mEq/L

Correct answer: A

Rationale: The correct answer is A: Potassium 3.5 mEq/L. Digoxin can cause hypokalemia as an adverse effect. Monitoring potassium levels is crucial because low potassium levels can increase the risk of digoxin toxicity. Choices B, C, and D are incorrect as they are not directly associated with potential adverse effects of digoxin. Sodium levels are not typically affected by digoxin, calcium levels are not a primary concern with digoxin therapy, and magnesium levels are not the most important to monitor for digoxin adverse effects.

5. What is the most appropriate action when a patient is experiencing severe dehydration?

• A. Administer IV fluids
• B. Encourage oral fluids
• C. Monitor electrolytes
• D. Perform a neurological exam

Correct answer: A

Rationale: The most appropriate action when a patient is experiencing severe dehydration is to administer IV fluids. This intervention is crucial in rapidly correcting dehydration and restoring fluid balance. Encouraging oral fluids may not be sufficient in cases of severe dehydration where intravenous rehydration is needed. Monitoring electrolytes is important but administering fluids takes precedence in severe dehydration. Performing a neurological exam is not the primary intervention for severe dehydration.

Similar Questions