Nursing Elites

1. A client who is postoperative and has paralytic ileus is being cared for by a nurse. Which of the following abdominal assessments should the nurse expect?

• A. Absent bowel sounds with distention
• B. Hyperactive bowel sounds
• C. Normal bowel sounds
• D. High-pitched bowel sounds

Correct answer: A

Rationale: In a client with paralytic ileus, absent bowel sounds with distention are expected due to decreased or absent bowel motility. This is a key characteristic of paralytic ileus, where the bowel is unable to contract and move contents along the digestive tract. Hyperactive bowel sounds (choice B) are more indicative of increased peristalsis, which is not typically seen in paralytic ileus. Normal bowel sounds (choice C) may not be present in a client with paralytic ileus. High-pitched bowel sounds (choice D) are not typically associated with paralytic ileus. Therefore, the correct assessment finding in this scenario is absent bowel sounds with distention.

2. The healthcare provider prescribes 1,000 ml of Ringer's Lactate with 30 Units of Pitocin to run over 4 hours for a client who has just delivered a 10-pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration set. The LPN/LVN plans to set the flow rate at how many gtt/min?

• A. 42 gtt/min
• B. 83 gtt/min
• C. 125 gtt/min
• D. 250 gtt/min

Correct answer: B

Rationale: To calculate the flow rate in drops per minute (gtt/min), the formula is Total volume (mL) ÷ Time (min) ÷ Drop factor (gtt/mL). In this case, 1000 mL ÷ 240 min ÷ 20 gtt/mL = 83 gtt/min. Therefore, setting the flow rate to 83 gtt/min ensures the correct administration of the IV fluids and medication. Choices A, C, and D are incorrect as they do not align with the correct calculation based on the provided information.

3. When transferring a client to a long-term care facility, what information should the nurse include in the handoff report?

• A. Frequency of previous vital sign measurements
• B. Number of family members who have visited
• C. Time of the client's last bath
• D. Effectiveness of the last dose of pain medication

Correct answer: D

Rationale: The correct answer is D: 'Effectiveness of the last dose of pain medication.' When transferring a client to a long-term care facility, it is crucial to provide information on the effectiveness of the last dose of pain medication to ensure continuity of care and appropriate pain management. This information helps the receiving facility understand the client's current pain status and plan future interventions accordingly. Choices A, B, and C are less relevant for the handoff report in this scenario. The frequency of previous vital sign measurements may be important, but the immediate effectiveness of pain medication takes precedence. The number of family members who have visited and the time of the client's last bath are not as critical for the receiving facility's immediate care planning compared to pain management details.

4. When explaining the fecal occult blood testing procedure to a client, which of the following information should be included?

• A. Eating more protein is not necessary before testing.
• B. Multiple stool specimens may be required for testing.
• C. A red color change indicates a positive test.
• D. The specimen must not be contaminated with urine.

Correct answer: D

Rationale: The correct answer is D. When performing fecal occult blood testing, it is crucial to inform the client that the specimen must not be contaminated with urine to prevent false results. Choices A and B are incorrect because eating more protein is not required before testing, and multiple stool specimens may be necessary for accurate results, respectively. Additionally, regarding choice C, a red color change, not blue, indicates a positive test result, making it an incorrect option.

5. During an admission history, a client tells a nurse that she is under a lot of stress. Which of the following physiological responses should the nurse expect to increase as a result of stress?

• A. Blood glucose - a common stress response.
• B. Intestinal peristalsis - should decrease due to stress.
• C. Peripheral blood vessels diameter - can vary in response to stress.
• D. Urine output - may vary but not a typical stress response.

Correct answer: A

Rationale: The correct answer is A. Stress typically increases blood glucose levels due to the release of stress hormones like cortisol and adrenaline. Elevated blood glucose helps provide energy for the body to cope with the stressful situation. Choice B is incorrect because intestinal peristalsis, the movement of the intestines, is more likely to decrease under stress due to the 'fight or flight' response. Choice C is incorrect as peripheral blood vessels' diameter may vary in response to stress, with both constriction and dilation possible. Choice D is incorrect as urine output may increase or decrease depending on individual differences and the specific stress response, but it is not a typical or direct physiological response to stress.

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