Nursing Elites

1. The nurse has given post-procedure instructions to a client who underwent a colonoscopy. Evaluation of learning would be evident if the client makes which statement(s)?

• A. All of the above
• B. “My abdominal muscles may be tender because of the procedure.”
• C. “My diet should be light at first, and then I can progress to a regular diet.”
• D. “It is normal to feel gassy or bloated for a short while after the procedure.”

Correct answer: A

Rationale: The correct answer is A: "All of the above." Evaluation of learning after a colonoscopy would be evident if the client mentions all the statements provided. Mild tenderness in the abdominal muscles, starting with a light diet and progressing to a regular diet, and experiencing gas or bloating temporarily are all expected after a colonoscopy. Therefore, all the statements are correct in demonstrating the client's understanding of the post-procedure instructions. Choices B, C, and D provide accurate information about the expected outcomes following a colonoscopy, making them incorrect answers individually but correct when combined as option A.

2. The nurse teaches the mother of an infant how to care for her infant following repair of a cleft lip. It is MOST important for the nurse to include which of the following instructions?

• A. Feed the infant with a newborn nipple while holding him in the recumbent position
• B. Clean the suture site with a cotton-tipped swab soaked in Betadine
• C. Place the infant in the prone position after feeding
• D. Feed the infant with a rubber-tipped syringe and burp frequently

Correct answer: D

Rationale: The correct answer is D because feeding the infant with a rubber-tipped syringe reduces the risk of injury to the surgical site and prevents aspiration. Choice A is incorrect because feeding an infant with a cleft lip using a newborn nipple while in the recumbent position can increase the risk of aspiration. Choice B is incorrect as Betadine is not typically used on suture sites due to its cytotoxic effects. Choice C is incorrect because placing the infant in the prone position after feeding can also increase the risk of aspiration.

3. The nurse is caring for a client who goes into ventricular tachycardia. Which intervention should the nurse implement first?

• A. Call a code immediately
• B. Assess the client for a pulse
• C. Begin chest compressions
• D. Continue to monitor the client

Correct answer: B

Rationale: The correct first intervention when a client goes into ventricular tachycardia is to assess for a pulse. This is crucial as the presence or absence of a pulse guides subsequent actions. Initiating chest compressions or calling a code should only be done after confirming the absence of a pulse. Continuing to monitor the client without checking for a pulse delays potentially life-saving interventions.

4. Which laboratory data indicate the client’s pancreatitis is improving?

• A. The amylase and lipase serum levels are decreased
• B. The white blood cell count (WBC) is decreased
• C. The conjugated and unconjugated bilirubin levels are decreased
• D. The blood urea nitrogen (BUN) serum level is decreased

Correct answer: A

Rationale: The correct answer is A. Amylase and lipase are enzymes specifically related to pancreatitis. A decrease in their serum levels indicates improvement in pancreatitis. White blood cell count (WBC), choices C and D, are not direct markers for pancreatitis improvement. Bilirubin levels, choice C, are more related to liver function rather than pancreatitis. Blood urea nitrogen (BUN) level, choice D, is a marker for kidney function, not pancreatitis.

5. When does the nurse act as a client advocate?

• A. Pulling the curtain around the client's bed while changing a dressing
• B. Contacting the health care provider to request a meeting for the client
• C. Ensuring access to medical information by appropriate personnel only
• D. All of the above

Correct answer: D

Rationale: The correct answer is D, 'All of the above.' Acting as a client advocate involves various actions to protect the client's rights and well-being. Pulling the curtain around the client's bed while changing a dressing ensures privacy and dignity. Contacting the health care provider to request a meeting for the client facilitates communication and addresses the client's needs. Ensuring access to medical information by appropriate personnel only safeguards the client's confidentiality and privacy. Therefore, all the actions mentioned in choices A, B, and C are examples of a nurse acting as a client advocate, making D the correct answer.

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