Nursing Elites

1. A nurse is assessing a client who is post-op day #3 after an abdominal hernia repair. After a bout of harsh coughing, the client states, 'it feels like something gave way.' The nurse assesses his abdomen and notes an evisceration from the surgical site. What is the next action of the nurse?

• A. Turn the client on his side
• B. Push the abdominal contents back inside the wound using sterile gloves
• C. Ask the client to take a breath and hold it
• D. Cover the intestine with sterile saline dressings

Correct answer: D

Rationale: A wound evisceration occurs when the edges of an abdominal wound separate, allowing the coils of the intestine to protrude outside of the body. The nurse should notify the physician at once if this occurs. While waiting for treatment, the nurse should cover the intestines with sterile gauze soaked in saline. Turning the client on his side or asking the client to take a breath and hold it are not appropriate actions in this situation. Pushing the abdominal contents back inside the wound using sterile gloves can lead to infection and is not within the nurse's scope of practice.

2. The patient in the emergency room has a history of alprazolam (Xanax) abuse and abruptly stopped taking Xanax about 24 hours ago. He presents with visible tremors, pacing, fear, impaired concentration, and memory. Which intervention takes priority?

• A. Have the patient lie down on a stretcher with bed rails raised
• B. Offer the patient a cup of water and a small amount of food
• C. Reassure the patient about his well-being
• D. Inform the physician about the patient's Xanax withdrawal

Correct answer: A

Rationale: The 1-4 day period after Xanax withdrawal is critical as it poses the highest risk of life-threatening seizures. Alprazolam is a benzodiazepine, and sudden cessation can lead to severe withdrawal symptoms. The patient's visible tremors, fear, pacing, and cognitive impairment indicate a state of heightened distress and potential seizure risk. Placing the patient on a stretcher with raised bed rails is essential for seizure precautions, ensuring safety and preventing injury during a potential seizure. Offering water and food, reassuring the patient, or informing the physician about Xanax withdrawal are not immediate priorities compared to managing the risk of seizures in this high-risk situation.

3. A client using an intraaural hearing aid experiences whistling after placement. What is the nurse's next action?

• A. Try to reposition the hearing aid
• B. Change the batteries
• C. Remove the device and have it cleaned
• D. Notify the physician that the hearing aid is not working

Correct answer: A

Rationale: An intraaural hearing aid, also known as an in-the-ear hearing aid, is placed in the ear canal. Whistling after placement indicates improper positioning of the device. The correct action for the nurse is to try repositioning the hearing aid to eliminate the whistling. Changing the batteries is not necessary for addressing whistling. Removing the device to clean it is not the immediate action needed for whistling. Notifying the physician is premature without attempting to reposition the hearing aid first.

4. The parent of an infant diagnosed with gastroesophageal reflux disease is receiving feeding instructions from the nurse. Which instruction should the nurse give to the parent to assist in reducing the episodes of emesis?

• A. Provide smaller, more frequent feedings.
• B. Burp the infant frequently during feedings.
• C. Thin the feedings by adding water to the formula.
• D. Thicken the feedings by adding rice cereal to the formula.

Correct answer: D

Rationale: Gastroesophageal reflux disease involves the backward flow of gastric contents into the esophagus due to sphincter issues. To reduce episodes of emesis, it is recommended to thicken feedings by adding rice cereal to the formula. This helps to weigh down the contents in the stomach, making regurgitation less likely. Providing smaller, more frequent feedings and burping the infant frequently are beneficial strategies for gastroesophageal reflux. However, in this case, thickening the feedings is the most appropriate intervention. Thinning the feedings by adding water to the formula is not recommended as it can decrease the caloric density of the formula and may not help in reducing reflux.

5. The nurse has provided dietary instructions to the mother of a child with celiac disease. The nurse determines that further instruction is needed if the mother states that she will include which food item in the child's nutritional plan?

• A. Corn
• B. Chicken
• C. Oatmeal
• D. Vitamin supplements

Correct answer: C

Rationale: In celiac disease, individuals need to avoid gluten-containing foods like wheat, rye, barley, and oats. Oatmeal contains gluten unless it is specifically labeled as gluten-free. Corn and rice are safe alternatives for individuals with celiac disease as they do not contain gluten. Chicken is a naturally gluten-free protein source. While vitamin supplements may be necessary to address deficiencies due to malabsorption, oatmeal poses a risk of gluten exposure, making it an incorrect choice for a child with celiac disease.

Similar Questions