Nursing Elites

1. The nurse is caring for a client who is 2 days post-op following an abdominal hysterectomy. The client reports feeling something 'give way' in the incision site and there is a small amount of bowel protruding from the wound. What action should the nurse take first?

• A. Apply a sterile saline dressing to the wound
• B. Notify the healthcare provider
• C. Administer pain medication
• D. Cover the wound with an abdominal binder

Correct answer: A

Rationale: In this situation, the priority action for the nurse is to apply a sterile saline dressing to the wound. This helps to cover and protect the exposed bowel, preventing infection and maintaining a moist environment for wound healing. Option B, notifying the healthcare provider, is important but should come after addressing the immediate need of covering the wound. Administering pain medication (option C) and covering the wound with an abdominal binder (option D) are not appropriate initial actions for this situation.

2. A client who has had three spontaneous abortions is requesting information about possible causes. The nurse's response should be based on which information?

• A. Chromosomal abnormalities are the most common cause of early spontaneous abortions
• B. Incompetent cervix can cause spontaneous abortions
• C. An infection can cause spontaneous abortions
• D. Nutritional deficiencies are the most common cause of early spontaneous abortions

Correct answer: A

Rationale: The correct answer is A: Chromosomal abnormalities are the most common cause of early spontaneous abortions. Spontaneous abortions, also known as miscarriages, often occur due to chromosomal abnormalities in the fetus. These abnormalities are a common cause of early pregnancy loss. Choice B is incorrect because an incompetent cervix typically leads to late miscarriages, not early spontaneous abortions. Choice C is incorrect as while infections can be a cause of spontaneous abortions, they are not the most common cause. Choice D is incorrect as nutritional deficiencies are not the most common cause of early spontaneous abortions.

3. The nurse working in an emergency center collects physical evidence 6 hours following a reported sexual assault. After placing the samples in sealed containers, which action is most important for the nurse to implement?

• A. Maintain possession of the evidence collection kit at all times until submitted to law enforcement
• B. Provide discharge instructions for prophylactic antibiotics, pregnancy, and HIV prevention medication
• C. Document the characteristics of the various sites of sample collection
• D. Assist the client with toileting, hygiene, and dressing with clean clothes

Correct answer: A

Rationale: Maintaining possession of the evidence collection kit at all times until submitted to law enforcement is crucial to ensure the integrity of the chain of custody. This step helps prevent tampering or contamination of the evidence, which is vital for the legal process. Providing discharge instructions for medications, documenting sample characteristics, and assisting the client with personal care are important aspects of care but not the immediate priority when handling forensic evidence in a sexual assault case.

4. A nurse is planning care for a client in the late stage of amyotrophic lateral sclerosis (ALS). Which nursing diagnosis has the highest priority?

• A. Impaired physical mobility
• B. Ineffective breathing pattern
• C. Impaired skin integrity
• D. Risk for infection

Correct answer: B

Rationale: Ineffective breathing pattern is the highest priority for a client in the late stage of ALS due to the significant risk of respiratory complications. As ALS progresses, the client may experience respiratory muscle weakness, leading to ineffective breathing patterns and potential respiratory failure. Addressing breathing difficulties promptly is crucial to ensure adequate oxygenation and prevent further complications. While impaired physical mobility, impaired skin integrity, and risk for infection are also important concerns in ALS care, they are secondary to addressing the client's breathing difficulties, which take precedence to maintain physiological stability and prevent life-threatening consequences.

5. Oxygen at liters/min per nasal cannula PRN difficult breathing is prescribed for a client with pneumonia. Which nursing intervention is effective in preventing oxygen toxicity?

• A. Avoiding the administration of high levels of oxygen for extended periods.
• B. Administering a sedative at bedtime to slow the client's respiratory rate.
• C. Removing the nasal cannula during the night to prevent oxygen buildup.
• D. Running oxygen through a hydration source prior to administration.

Correct answer: A

Rationale: The correct answer is A: Avoiding the administration of high levels of oxygen for extended periods. Oxygen toxicity can occur when high levels of oxygen are given for a prolonged period. It is important to monitor and adjust the oxygen levels as needed to prevent toxicity. Choice B is incorrect because administering a sedative to slow the respiratory rate does not directly prevent oxygen toxicity. Choice C is incorrect as removing the nasal cannula during the night can compromise the client's oxygenation. Choice D is incorrect as running oxygen through a hydration source does not prevent oxygen toxicity; instead, it may introduce risks associated with the hydration source.

Similar Questions