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 caring for a client who is 1 hour postoperative following a thoracentesis. Which of the following findings should the nurse report to the provider?

• A. Oxygen saturation of 96%
• B. Tracheal deviation
• C. Pain level of 4 on a scale of 0 to 10
• D. Temperature of 37.4°C (99.3°F)

Correct answer: B

Rationale: Tracheal deviation is the correct finding to report to the provider. It can indicate a pneumothorax, which is a serious complication following a thoracentesis that requires immediate attention. Oxygen saturation of 96% is within the normal range and does not indicate an immediate issue. A pain level of 4 on a scale of 0 to 10 is subjective and may not be related to a serious complication. A temperature of 37.4°C (99.3°F) is slightly elevated but not a priority over tracheal deviation in this context.

3. A client, 12 hours postpartum, reports not having a bowel movement for 4 days. Which medication should the nurse administer?

• A. Bisacodyl 10 mg rectal suppository.
• B. Magnesium hydroxide 30 ml PO.
• C. Famotidine 20 mg PO.
• D. Loperamide 4 mg PO.

Correct answer: A

Rationale: In this scenario, the nurse should administer Bisacodyl 10 mg rectal suppository. The client's report of not having a bowel movement for 4 days indicates constipation, and Bisacodyl is a stimulant laxative that helps initiate bowel movements. Magnesium hydroxide is an antacid and osmotic laxative used for indigestion, not for constipation. Famotidine is an H2 receptor antagonist used to reduce stomach acid production and treat heartburn, not constipation. Loperamide is an antidiarrheal agent and would be contraindicated in a client experiencing constipation.

4. While caring for a newborn with jaundice receiving phototherapy, what action should the nurse take?

• A. Feed the infant 30 ml (1 oz) of glucose water every 2 hours.
• B. Keep the infant's head covered with a cap.
• C. Ensure that the newborn wears a diaper.
• D. Apply lotion to the newborn every 4 hours.

Correct answer: C

Rationale: The correct action for the nurse to take while caring for a newborn with jaundice receiving phototherapy is to ensure that the newborn wears a diaper. This is essential to prevent skin irritation during phototherapy. Feeding the infant glucose water or applying lotion are not pertinent to managing jaundice or phototherapy. Keeping the infant's head covered with a cap is also not necessary for this specific situation.

5. A nurse is caring for a client who has experienced intimate partner violence. What is the nurse's priority?

• A. Develop a safety plan with the client.
• B. Refer the client to a community support group.
• C. Determine if the client has any injuries.
• D. Contact the client's family about the incident.

Correct answer: A

Rationale: The correct answer is A: 'Develop a safety plan with the client.' When caring for a client who has experienced intimate partner violence, the nurse's priority is to ensure the client's safety. Developing a safety plan is essential to address the immediate safety concerns and provide support to the client. Referring the client to a community support group, as in option B, may be beneficial but is not the immediate priority. While determining if the client has any injuries, as in option C, is important for assessing physical well-being, the priority is to address safety concerns first. Contacting the client's family about the incident, as in option D, is not appropriate without the client's consent and may further endanger the client.

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