Nursing Elites

1. A nurse is caring for a client who is 2 days postoperative following abdominal surgery and has a new prescription for a regular diet. For which of the following findings should the nurse notify the provider?

• A. Presence of bowel sounds
• B. Client reports nausea
• C. Client is vomiting
• D. Absent bowel sounds

Correct answer: D

Rationale: The correct answer is D. Absent bowel sounds are concerning as they indicate potential complications such as ileus, which is a risk after abdominal surgery. The absence of bowel sounds can suggest decreased or absent intestinal motility, which may lead to complications if not addressed promptly. The nurse should notify the provider immediately to assess the situation and intervene accordingly. Choices A and B are common postoperative occurrences and do not necessarily warrant immediate provider notification. Choice C, vomiting, while concerning, may be a common postoperative symptom; however, absent bowel sounds are a more critical finding that requires prompt attention.

2. A nurse at a long-term care facility is caring for a client who requires oral suctioning. Which of the following supplies should the nurse plan to use for this task?

• A. Yankauer catheter
• B. Bulb syringe
• C. Suction catheter
• D. Sterile gloves

Correct answer: A

Rationale: The correct answer is A: Yankauer catheter. The Yankauer catheter is specifically designed for oral suctioning, making it the most appropriate choice for this task. Choice B, the Bulb syringe, is typically used for suctioning small amounts of liquid from the nose or mouth. Choice C, the Suction catheter, is more commonly used for deep suctioning in the trachea or bronchi. Choice D, Sterile gloves, are necessary for infection control but are not the primary supply used for oral suctioning.

3. A nurse is contributing to the plan of care for a client who has a chest tube connected to a closed drainage system. Which of the following interventions should the nurse include?

• A. Clamp the chest tube
• B. Maintain the drainage below the level of the chest
• C. Elevate the chest tube above chest level
• D. Avoid frequent dressing changes

Correct answer: B

Rationale: The correct intervention for a client with a chest tube connected to a closed drainage system is to maintain the drainage below the level of the chest. This position allows proper drainage of fluids and helps prevent complications such as backflow of blood or fluids into the chest cavity. Clamping the chest tube (Choice A) is incorrect as it can lead to a tension pneumothorax. Elevating the chest tube above chest level (Choice C) is also incorrect because it can impede proper drainage. Avoiding frequent dressing changes (Choice D) is important to prevent introducing infection, but it is not directly related to the position of the drainage system.

4. A client has developed phlebitis at the IV site. What should the nurse do first?

• A. Apply a warm compress to the IV site
• B. Discontinue the IV and notify the provider
• C. Monitor the IV site for signs of infection
• D. Administer an anti-inflammatory medication

Correct answer: B

Rationale: When a client develops phlebitis at the IV site, the priority action for the nurse is to discontinue the IV and notify the provider. Phlebitis is inflammation of the vein, and removing the IV can help prevent further complications. Applying a warm compress may provide symptomatic relief but does not address the root cause. Monitoring for infection is important, but immediate action to remove the source of inflammation is crucial. Administering an anti-inflammatory medication is not the first-line intervention for phlebitis; removal of the IV is necessary.

5. A nurse is reinforcing teaching about ways to reduce solid fat consumption with a client who has an elevated cholesterol level. Which of the following instructions should the nurse include?

• A. Use oils with trans fats
• B. Choose lean cuts of beef
• C. Avoid purchasing beef that is a loin cut
• D. Purchase chicken instead of lamb

Correct answer: B

Rationale: The correct answer is B: 'Choose lean cuts of beef.' Selecting lean cuts of beef is crucial in reducing solid fat consumption for individuals with high cholesterol levels. Lean cuts contain less saturated fat compared to fatty cuts, thus aiding in managing cholesterol levels. Option A is incorrect as oils with trans fats should be avoided since they contribute to unhealthy fats. Option C is not directly related to reducing solid fat consumption. Option D, while suggesting a leaner meat option, does not address the issue of solid fat consumption as directly as choosing lean cuts of beef.

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