Nursing Elites

1. Following a classic cholecystectomy resection for multiple stones, the PACU nurse observes serosanguinous drainage on the dressing. The most appropriate intervention is to:

• A. notify the physician of the drainage
• B. change the dressing
• C. reinforce the dressing
• D. apply an abdominal binder

Correct answer: C

Rationale: In the context of a classic cholecystectomy resection, serosanguinous drainage is an expected finding postoperatively due to the nature of the surgery. The appropriate intervention in this situation is to reinforce the dressing. Changing the dressing prematurely can increase the risk of introducing infection. Applying an abdominal binder is not recommended as it can obstruct the visualization of the dressing and the underlying wound, making it difficult to monitor for any complications or changes in drainage. Notifying the physician may be necessary if there are significant changes in the drainage characteristics or other concerning signs, but the immediate action should be to reinforce the dressing to maintain a clean and secure environment for wound healing.

2. The client has an order for an IV piggyback of Ceftriaxone 750mg in 50mL D5W to run over 30 minutes. What is the appropriate drip rate?

• A. 100 mL/hr
• B. 150 mL/hr
• C. 200 mL/hr
• D. 50 mL/hr

Correct answer: A

Rationale: To calculate the drip rate, you need to convert the time from minutes to hours. The formula is (Volume to be infused / Time for infusion in minutes) x (60 minutes / 1 hour). Substituting the values, (50 mL / 30 min) x (60 min / 1 hr) = 100 mL/hr. Therefore, the appropriate drip rate is 100 mL/hr. Choices B, C, and D are incorrect as they do not match the calculated drip rate. Option A, 100 mL/hr, is the correct drip rate for administering Ceftriaxone 750mg in 50mL D5W over 30 minutes.

3. How often should the nurse change the intravenous tubing on total parenteral nutrition solutions?

• A. every 24 hours
• B. every 36 hours
• C. every 48 hours
• D. every 72 hours

Correct answer: A

Rationale: The correct answer is 'every 24 hours.' Changing the intravenous tubing on total parenteral nutrition solutions every 24 hours is crucial due to the high risk of bacterial growth. Bacterial contamination can lead to serious infections in patients receiving total parenteral nutrition. Choices B, C, and D are incorrect because waiting longer intervals between tubing changes increases the risk of bacterial contamination and infection, compromising patient safety. It is essential to maintain a strict 24-hour schedule to minimize the risk of complications associated with bacterial contamination.

4. When caring for pediatric clients, the nurse should pay special attention to the psychosocial development stages credited to whom?

• A. Robert Peck
• B. Erik Erikson
• C. Sigmund Freud
• D. Jean Piaget

Correct answer: B

Rationale: Erik Erikson is credited with the psychosocial development theory and eight stages. The nurse should consider these stages when caring for pediatric clients to evaluate their development. Jean Piaget is known for cognitive development, Sigmund Freud for psychosexual development, and Robert Peck for aging theory. Therefore, the correct answer is Erik Erikson.

5. A nurse is caring for a pregnant client in the labor unit who suddenly experiences spontaneous rupture of the membranes. On inspecting the amniotic fluid, the nurse notes that it is clear, with creamy white flecks. What is the most appropriate action for the nurse to take based on this finding?

• A. Check the client's temperature.
• B. Report the findings to the nurse-midwife.
• C. Obtain a sample of the amniotic fluid for laboratory analysis.
• D. Document the findings.

Correct answer: D

Rationale: Amniotic fluid should be clear and may include bits of vernix, the creamy white fetal skin lubricant. Therefore, the nurse would most appropriately document the findings. Checking the client's temperature, reporting the findings to the nurse-midwife, and obtaining a sample of the amniotic fluid for laboratory analysis are not necessary in this situation. Cloudy, yellow, or foul-smelling amniotic fluid suggests infection, while green fluid indicates that the fetus passed meconium before birth. If abnormalities are noted, the nurse should notify the nurse-midwife.

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