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. What are the signs and symptoms of fluid overload?

• A. Edema, shortness of breath, weight gain
• B. High blood pressure and jugular venous distention
• C. Low blood pressure and cyanosis
• D. Tachycardia and dizziness

Correct answer: A

Rationale: The correct signs and symptoms of fluid overload include edema, shortness of breath, and weight gain. Edema is the abnormal accumulation of fluid causing swelling, shortness of breath can occur due to fluid accumulating in the lungs, and weight gain is often seen as a result of excess fluid retention. Choices B, C, and D are incorrect because high blood pressure and jugular venous distention are more indicative of conditions like heart failure, while low blood pressure and cyanosis are seen in conditions like shock or poor perfusion. Tachycardia and dizziness are not typical signs of fluid overload.

3. A client with moderate anxiety disorder is being taught stress management techniques by a nurse. Which response by the client indicates an understanding of the teaching?

• A. I will take a walk to reduce my anxiety
• B. I will imagine myself in a calm place when I can't concentrate
• C. I will meditate every other week
• D. I will cut back on my caffeine intake

Correct answer: B

Rationale: The correct answer is B because imagining oneself in a calm place is a relaxation technique that helps reduce anxiety. Walking, meditating every other week, or cutting back on caffeine intake may have their benefits, but they are not as directly related to the immediate management of anxiety as the visualization technique described in option B.

4. A nurse is planning care for a client who is receiving hemodialysis via an AV fistula. Which of the following interventions should the nurse include in the plan of care?

• A. Avoid taking blood pressures on the arm with the AV fistula.
• B. Check the fistula site daily for pallor.
• C. Place a warm compress over the fistula site every 4 hours.
• D. Keep the client's arm elevated on two pillows.

Correct answer: A

Rationale: The correct intervention is to avoid taking blood pressures on the arm with the AV fistula. This is crucial to prevent complications such as damage to the fistula. Checking the fistula site for pallor is not as important as avoiding blood pressures on the affected arm. Placing warm compresses over the fistula site is not recommended as it can increase the risk of infection. Keeping the client's arm elevated on two pillows is not necessary for the care of an AV fistula.

5. How should a healthcare provider assess and manage a patient with a potential myocardial infarction (MI)?

• A. Assess symptoms, monitor vital signs, order ECG
• B. Administer medications and monitor for pain
• C. Administer thrombolytics and oxygen therapy
• D. Educate patient on lifestyle changes

Correct answer: A

Rationale: Correct Answer: A. When assessing a patient with a potential myocardial infarction, it is crucial to assess symptoms, monitor vital signs like blood pressure and heart rate, and order an electrocardiogram (ECG) to evaluate for cardiac abnormalities. Choice B is incorrect because administering medications should be based on the findings of the assessment and diagnostic tests, not administered indiscriminately. Choice C is incorrect because the administration of thrombolytics and oxygen therapy should be based on specific criteria and should be done in a controlled setting. Choice D is incorrect as educating the patient on lifestyle changes is important for prevention but is not the immediate priority when managing a potential myocardial infarction.

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