Nursing Elites

1. During a paracentesis, two liters of fluid are removed from the abdomen of a client with ascites. A drainage bag is placed, and 50 ml of straw-colored fluid drains within the first hour. What action should the nurse implement?

• A. Palpate for abdominal distention
• B. Send fluid to the lab for analysis
• C. Continue to monitor the fluid output
• D. Clamp the drainage tube for 5 minutes

Correct answer: C

Rationale: Continuing to monitor the fluid output is the appropriate action in this situation. Monitoring the fluid output helps the nurse assess the client's ongoing response to the procedure and detect any sudden changes, such as increased or decreased drainage rate, which could indicate complications. Palpating for abdominal distention, sending fluid to the lab for analysis, or clamping the drainage tube are not necessary actions at this point, as the priority is to monitor the client's condition post-procedure.

2. How often should the casts be changed for a newborn with talipes who is wearing casts?

• A. Daily
• B. Weekly
• C. Biweekly
• D. Monthly

Correct answer: B

Rationale: The correct answer is B: Weekly. Treatment of talipes involves manipulation and applying short leg casts. The casts need to be changed weekly to allow for further manipulation and to accommodate the rapid growth of the infant. Changing the casts daily (choice A) would be too frequent and may not provide enough time for the correction to take place. Changing the casts biweekly (choice C) or monthly (choice D) would not provide adequate support for the ongoing correction process required for talipes.

3. What assessment findings should lead the nurse to suspect Down syndrome in a newborn?

• A. Hypertonia and dark skin
• B. Low-set ears and a simian crease
• C. Inner epicanthal folds and a high, domed forehead
• D. Long, thin fingers and excessive hair

Correct answer: B

Rationale: The correct answer is B: 'Low-set ears and a simian crease.' These are key physical characteristics commonly seen in newborns with Down syndrome. Low-set ears, along with a simian crease (a single palmar crease), are indicative of Down syndrome. Choices A, C, and D are incorrect because hypertonia, dark skin, inner epicanthal folds, a high, domed forehead, long, thin fingers, and excessive hair are not specific features associated with Down syndrome in newborns. Therefore, the presence of low-set ears and a simian crease should raise suspicion for Down syndrome and prompt further evaluation.

4. While assessing a client with degenerative joint disease, the nurse observes Heberden's nodes, large prominences on the client's fingers that are reddened. The client reports that the nodes are painful. Which action should the nurse take?

• A. Review the client's dietary intake of high protein foods
• B. Notify the healthcare provider of the finding immediately
• C. Discuss approaches to chronic pain control with the client
• D. Assess the client's radial pulses and capillary refill time

Correct answer: C

Rationale: Discussing approaches to chronic pain control is the most appropriate action in this situation as it helps the client manage the chronic pain associated with Heberden's nodes. Reviewing the client's dietary intake of high protein foods (Choice A) is not directly related to managing the pain caused by Heberden's nodes. Notifying the healthcare provider immediately (Choice B) may not be necessary unless there are urgent complications. Assessing the client's radial pulses and capillary refill time (Choice D) is important but not the priority in addressing the client's reported pain and the presence of Heberden's nodes.

5. To assess the quality of an adult client’s pain, what approach should the nurse use?

• A. Ask the client to rate the pain on a scale of 1 to 10.
• B. Ask the client to describe the pain.
• C. Observe the client’s nonverbal cues.
• D. Determine the client’s pain tolerance.

Correct answer: B

Rationale: The correct approach for assessing the quality of an adult client's pain is to ask the client to describe the pain. By doing so, the nurse gains valuable information about the quality, location, and nature of the pain directly from the client. This approach allows for a more comprehensive understanding of the pain experience. Choice A, asking the client to rate the pain on a scale of 1 to 10, focuses more on intensity rather than quality. Choice C, observing the client's nonverbal cues, can provide additional information but may not fully capture the client's subjective experience of pain. Choice D, determining the client's pain tolerance, is not directly related to assessing the quality of pain but rather to how much pain a client can endure.

Similar Questions