Nursing Elites

1. What is the primary focus of postoperative nursing care for the client with colon trauma?

• A. Monitoring for elevated coagulation studies
• B. Observation for and prevention of fistulas
• C. Monitoring for signs of hyponatremia
• D. Observation for and prevention of infection

Correct answer: D

Rationale: The correct answer is D: Observation for and prevention of infection. Postoperative nursing care for a client with colon trauma primarily focuses on preventing infections. Clients with colon trauma are at high risk for infections due to the disruption of the intestinal barrier. Monitoring for signs of infection, maintaining proper wound care, administering antibiotics as prescribed, and implementing strict aseptic techniques are essential in preventing postoperative infections. Choices A, B, and C are incorrect because elevated coagulation studies, fistulas, and hyponatremia are not the primary concerns in the immediate postoperative period for a client with colon trauma.

2. A 9-year-old received a short arm cast for a right radius. To relieve itching under the child’s cast, which instructions should the nurse provide to the parents?

• A. Blow cool air from a hair dryer under the cast
• B. Twist the cast back and forth
• C. Shake powder into the cast
• D. Push a pencil under the cast edge

Correct answer: A

Rationale: Blowing cool air from a hair dryer under the cast is a safe method to relieve itching without damaging the cast or causing injury. The air helps to dry out the moisture that is causing the itching. Twisting the cast back and forth (choice B) can create pressure points and discomfort for the child. Shaking powder into the cast (choice C) can introduce foreign material that may cause skin irritation. Pushing a pencil under the cast edge (choice D) can injure the child's skin or even dislodge the cast.

3. A 14-year-old male client with a spinal cord injury (SCI) at T-10 is admitted for rehabilitation. During the morning assessment, the nurse determines that the adolescent's face is flushed, his forehead is sweating, his heart rate is 54 beats/min, and his blood pressure is 198/118. What action should the nurse implement first?

• A. Determine if the urinary bladder is distended
• B. Irrigate the indwelling urinary catheter
• C. Review the temperature graph for the last day
• D. Administer an antihypertensive agent

Correct answer: A

Rationale: Autonomic dysreflexia is a potentially life-threatening emergency that can be triggered by a distended bladder in clients with spinal cord injuries at T-6 or above. The priority action is to determine if the urinary bladder is distended as this could be the cause of the symptoms observed in the adolescent. Flushing, sweating, bradycardia, and severe hypertension are classic signs of autonomic dysreflexia. Irrigating the urinary catheter, reviewing temperature graphs, or administering an antihypertensive agent are not the initial actions to take when suspecting autonomic dysreflexia.

4. The client had gastric bypass surgery yesterday. Which intervention is most important for the nurse to implement during the first 24 postoperative hours?

• A. Insert an indwelling urinary catheter
• B. Monitor for the appearance of an incisional hernia
• C. Instruct the client to eat small frequent meals
• D. Measure hourly urinary output

Correct answer: D

Rationale: Monitoring hourly urinary output is crucial during the first 24 postoperative hours to assess kidney function, fluid balance, and early detection of complications like dehydration or inadequate kidney perfusion. Inserting an indwelling urinary catheter is not routinely necessary after gastric bypass surgery unless there are specific indications. Monitoring for an incisional hernia is important but not the highest priority in the immediate postoperative period. Instructing the client to eat small frequent meals is essential for long-term dietary management after gastric bypass surgery, but not the most critical intervention during the initial 24 hours.

5. To prevent aspiration in a client on mechanical ventilation receiving continuous enteral feedings through a nasogastric tube, which intervention is most important for the nurse to implement?

• A. Verify the feeding tube position with a daily chest x-ray
• B. Maintain head of bed elevated while enteral feeding is infusing
• C. Check feeding tube placement with air bolus prior to use
• D. Aspirate stomach contents every 4 hours to assess residuals

Correct answer: B

Rationale: The most important intervention to prevent aspiration in a client receiving continuous enteral feedings through a nasogastric tube while on mechanical ventilation is to maintain the head of the bed elevated while the feeding is infusing. This position helps reduce the risk of regurgitation and aspiration. Options A, C, and D are not as crucial as maintaining proper positioning to prevent aspiration. Verifying tube position with a daily chest x-ray is important but not the most crucial. Checking tube placement with an air bolus and aspirating stomach contents are important procedures but do not directly address the prevention of aspiration during enteral feedings.

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