Nursing Elites

1. When changing the client's dressing, which observation should the nurse report to the client's surgeon for a client recovering from an appendectomy for a ruptured appendix with a surgical wound healing by secondary intention?

• A. A halo of erythema on the surrounding skin
• B. Presence of serous drainage
• C. Edema around the wound
• D. Absence of granulation tissue

Correct answer: A

Rationale: A halo of erythema on the surrounding skin may indicate an infection or inflammation of the wound site, which is critical to report to the surgeon. Erythema, redness, and warmth are signs of inflammation that could potentially be a sign of an infected wound. Serous drainage is a common and expected finding in healing wounds, indicating a normal healing process. Edema around the wound might be expected due to the body's response to tissue injury. The absence of granulation tissue in a wound healing by secondary intention may not be an immediate concern as it forms during the later stages of wound healing.

2. What should be done when caring for a client who died?

• A. Obtain orders, Remove tubes, Wash client, Ask family, Place tags.
• B. Wash client, Obtain orders, Place tags, Remove tubes, Ask family.
• C. Remove tubes, Obtain orders, Ask family, Place tags, Wash client.
• D. Ask family, Place tags, Wash client, Remove tubes, Obtain orders.

Correct answer: A

Rationale: When caring for a deceased client, the correct sequence of actions involves first obtaining any necessary orders, then removing tubes, washing the client, asking the family for specific requests, and finally placing identification tags. This order ensures proper care and respect for the deceased individual. Option A presents the correct order of actions. Choice B is incorrect because washing the client should be done after removing tubes. Choice C is incorrect as it does not follow the correct order of actions. Choice D is incorrect because asking the family should be done after caring for the client's body, not before.

3. A healthcare professional is caring for a child who has a prescription for a blood transfusion. The parents have refused the treatment due to religious beliefs. Which of the following actions should the healthcare professional take?

• A. Examine personal values about the issue.
• B. Respect the parents' decision and provide alternative treatment options.
• C. Seek a court order to proceed with the transfusion.
• D. Discuss the issue with the child.

Correct answer: A

Rationale: Examining personal values about the issue is crucial for the healthcare professional to provide unbiased care while still respecting the parents' beliefs. Choice B is incorrect because respecting the parents' decision is essential, but providing alternative treatment options may not be warranted in this situation where the parents' decision is based on religious beliefs. Seeking a court order (Choice C) should only be considered as a last resort when the child's life is in immediate danger and all other options have been exhausted. Discussing the issue with the child (Choice D) may not be appropriate as the child may not fully comprehend the situation or the implications of going against the parents' beliefs.

4. A nurse is preparing to administer ketorolac 0.5 mg/kg IV bolus every 6 hr to a school-age child who weighs 66 lb. The available ketorolac injection is 30 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

• A. 0.5 mL
• B. 1 mL
• C. 1.5 mL
• D. 2 mL

Correct answer: A

Rationale: To calculate the dose, first convert the weight from pounds to kilograms. The child weighs 66 lb, which is approximately 30 kg. The prescribed dose is 0.5 mg/kg, so for a 30 kg child, the dose would be 0.5 mg/kg x 30 kg = 15 mg. Since the available ketorolac injection is 30 mg/mL, the nurse should administer 15 mg ÷ 30 mg/mL = 0.5 mL per dose. Therefore, choice A (0.5 mL) is the correct answer. Choices B, C, and D are incorrect as they do not accurately calculate the correct dose based on the child's weight and the concentration of the ketorolac injection.

5. A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?

• A. Compare prescriptions with medications the client received during hospitalization.
• B. Only review the client’s current medications.
• C. Provide a list of medications without checking for interactions.
• D. Discuss the client’s medication history without verification.

Correct answer: A

Rationale: The correct answer is A: Compare prescriptions with medications the client received during hospitalization. This step is crucial in ensuring the accuracy of medication reconciliation. By comparing the current prescriptions with the medications administered during the hospital stay, the nurse can identify any discrepancies, omissions, or duplications in the medications. This comprehensive comparison helps prevent medication errors and ensures that the client's home medications align with the treatment received in the hospital. Choice B is incorrect because solely reviewing the client's current medications may overlook important changes or additions made during the hospitalization. Choice C is incorrect as providing a list of medications without checking for interactions can lead to potential adverse effects or drug interactions. Choice D is incorrect as discussing the client's medication history without verification may not provide an accurate representation of the medications the client actually received during the hospital stay.

Similar Questions