Nursing Elites

1. Following a child's return from exploratory surgery due to a gunshot wound to the abdomen, which nursing intervention should be excluded from the plan of care?

• A. Immediate initiation of oral feedings
• B. Assessment of the surgical site
• C. Administration of opioid narcotics for pain management
• D. Visitation at the bedside

Correct answer: A

Rationale: Immediate initiation of oral feedings should be excluded from the plan of care post-abdominal surgery due to the risk of bowel complications like paralytic ileus or anastomotic leak. Starting oral feedings immediately can increase these risks and hinder healing. It is crucial to wait until bowel function returns and the patient shows signs of tolerance before introducing oral feedings. Assessment of the surgical site is necessary to monitor for any signs of infection or complications. Administration of opioid narcotics for pain management is essential for ensuring the patient's comfort post-surgery. Visitation at the bedside provides emotional support and can aid in the patient's recovery. Therefore, the correct answer is to exclude immediate initiation of oral feedings.

2. Which strategy is most effective in preventing existing challenging behaviors?

• A. Ignoring the behaviors
• B. Individualized interventions
• C. Providing flexible rules
• D. Punishment

Correct answer: B

Rationale: Individualized interventions are tailored to address the specific needs and triggers of the individual's challenging behaviors. By customizing the approach to each person, it increases the likelihood of effectively preventing and managing the existing challenging behaviors.

3. The patient taking spironolactone (Aldactone) makes a statement indicating effective teaching. Which statement shows understanding of the teaching?

• A. I will use salt substitutes to lower my sodium intake
• B. I will increase my intake of foods that are high in potassium
• C. I will call my doctor if I begin having menstrual irregularities
• D. I will take this medication at bedtime each evening

Correct answer: C

Rationale: The correct answer is C because spironolactone is a potassium-sparing diuretic that can cause endocrine effects like menstrual irregularities. Therefore, the patient recognizing the need to report such changes indicates effective teaching. Choices A and B are incorrect as salt substitutes and high-potassium foods should be avoided with spironolactone. Choice D is also incorrect because diuretics, including spironolactone, are ideally taken in the morning to prevent disturbances in sleep due to nocturia.

4. A nurse is planning care for a 2-month-old infant who is postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take?

• A. Position the infant on his abdomen
• B. Cleanse the incision site with hydrogen peroxide
• C. Offer the infant a pacifier
• D. Keep the infant's elbow restrained

Correct answer: D

Rationale: The nurse should keep the infant�s elbow restrained to prevent injury to the surgical site.

5. A school-age child has peripheral edema. Which of the following assessments should the nurse perform to confirm peripheral edema?

• A. Palpate the dorsum of the child's feet
• B. Weigh the child daily using the same scale
• C. Assess the child's skin turgor
• D. Observe the child for periorbital swelling

Correct answer: A

Rationale: To confirm peripheral edema in a child, the nurse should palpate the dorsum of the child's feet by pressing a fingertip against a bony prominence for 5 seconds. This assessment helps detect the presence of pitting edema, which is characterized by an indentation that remains after the pressure is released.

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