Nursing Elites

1. A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period?

• A. Teaching perineal wound care techniques
• B. Monitoring electrolyte levels
• C. Encouraging early ambulation
• D. Facilitating perineal wound drainage

Correct answer: D

Rationale: The priority nursing care during the post-op period for a client who underwent an abdominal perineal resection is to facilitate perineal wound drainage. This is crucial for preventing infection of the surgical site and promoting healing. Teaching perineal wound care techniques, as in choice A, is more appropriate than ileostomy care in this scenario. While monitoring electrolyte levels is important, it is not the priority compared to ensuring proper wound drainage, making choice B less crucial. Encouraging early ambulation, as in choice C, is beneficial but not as critical as facilitating wound drainage immediately post-op.

2. Why might the physician order antibiotics to be given through the central venous access device (CVAD) rather than through a peripheral IV line if the CVAD becomes infected?

• A. To prevent infiltration of the peripheral line
• B. To reduce the pain and discomfort associated with antibiotic administration in a small vein
• C. To lessen the chance of an allergic reaction to the antibiotic
• D. To attempt to eliminate microorganisms in the catheter and prevent having to remove it

Correct answer: D

Rationale: When a patient's central venous access device (CVAD) becomes infected, administering antibiotics through the line is essential to attempt to eliminate microorganisms within the catheter. The goal is to prevent the necessity of removing the catheter, which might be required if the infection persists. Choice A, 'To prevent infiltration of the peripheral line,' is incorrect as the priority is addressing the catheter infection, not preventing issues with a peripheral line. Choice B, 'To reduce the pain and discomfort associated with antibiotic administration in a small vein,' is not relevant to the rationale for choosing the CVAD for antibiotic administration. Choice C, 'To lessen the chance of an allergic reaction to the antibiotic,' is also incorrect as the main focus is managing the catheter-associated infection rather than allergy prevention.

3. During a well-baby check of a 6-month-old infant, the nurse notes abrasions and petechiae of the palate. The nurse should:

• A. inquire about the possibility of sexual abuse.
• B. ask about the types of foods the child is eating.
• C. request to see the type of bottle used for feedings.
• D. question the parent about objects the child plays with.

Correct answer: A

Rationale: The correct answer is to inquire about the possibility of sexual abuse. Injuries to the soft palate such as bruising, abrasions, and petechiae can be signs of sexual abuse in infants. While oral sex may not leave significant physical evidence, these findings should raise suspicion. Option A is correct as it focuses on addressing potential abuse. Options B, C, and D are incorrect because the child's diet, the type of bottle used for feedings, and play objects are not likely related to the observed injuries. The presence of oral injuries suggests considering sexual abuse rather than other factors.

4. A nurse notes that an elderly client suddenly does not keep appointments and is not wearing appropriate clothing. Which statement by the client raises the suspicion of financial abuse?

• A. "I am having difficulty paying for this new antibiotic the physician prescribed."?
• B. "I am a little short on cash since my daughter moved in to help me."?
• C. "I have not felt like shopping since the weather has gotten worse."?
• D. "People do not realize how difficult it is to make ends meet on a fixed income."?

Correct answer: B

Rationale: The correct answer is B: "I am a little short on cash since my daughter moved in to help me."? This statement raises suspicion of financial abuse as it suggests a recent change in financial circumstances after the daughter moved in. Financial abuse in elderly clients can be indicated by sudden unexplained financial deficits or changes, such as difficulty paying for necessities despite previously being able to do so. Choices A, C, and D do not directly imply a recent financial change due to external factors, making them less indicative of potential financial abuse. Option B is the most concerning statement that warrants further investigation into possible financial exploitation.

5. A client with schizophrenia says, 'I'm away for the day ... but don't think we should play "? or do we have feet of clay?' Which alteration in the client's speech does the nurse document?

• A. Neologism
• B. Word salad
• C. Clang association
• D. Associative looseness

Correct answer: D

Rationale: The correct answer is 'Associative looseness.' In the provided speech, the client shows associative looseness by making loose connections between phrases without a clear logical link. Clang association involves rhyming words without regard for their meaning. Neologism refers to made-up words with specific meaning to the client, and word salad is a jumble of words that lack coherence either to the listener or the client. Understanding these speech patterns associated with schizophrenia is crucial in identifying the specific alteration in speech displayed by the client in this scenario.

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