Nursing Elites

1. A nurse is planning care for a school-age child who is 4 hours postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care?

• A. Offer small amounts of clear liquids 6 hours following surgery.
• B. Give cromolyn nebulizer solution every 6 hours.
• C. Apply a warm compress to the operative site every 4 hours.
• D. Administer analgesics on a scheduled basis for the first 24 hours.

Correct answer: D

Rationale: Administering analgesics on a scheduled basis for the first 24 hours is crucial in managing postoperative pain for the child. This helps control pain levels effectively, promoting comfort and aiding in the recovery process. Offering small amounts of clear liquids 6 hours following surgery may not be appropriate as the child may need time to recover from anesthesia. Giving cromolyn nebulizer solution every 6 hours is not indicated for postoperative care following appendicitis surgery. Applying a warm compress every 4 hours to the operative site may not be recommended as it can potentially interfere with the surgical wound healing process.

2. A nurse is assessing a client who has pneumonia. Which of the following findings should the nurse report to the provider?

• A. Crackles in the lung bases
• B. Oxygen saturation of 95%
• C. Heart rate of 88/min
• D. Frequent productive cough

Correct answer: A

Rationale: The correct answer is A: Crackles in the lung bases. In a client with pneumonia, crackles in the lung bases can indicate fluid accumulation, suggesting worsening respiratory status. This finding should be reported to the provider for further evaluation and management. Choice B, an oxygen saturation of 95%, is within the normal range and does not require immediate reporting. Choice C, a heart rate of 88/min, is also within normal limits and does not indicate an urgent need for intervention. Choice D, a frequent productive cough, is a common symptom in pneumonia and may not require immediate reporting unless it is severe or worsening. Therefore, crackles in the lung bases are the most concerning finding that warrants prompt attention.

3. How should a healthcare professional monitor a patient with a central line for infection?

• A. Monitor the dressing site daily
• B. Check for redness and swelling
• C. Monitor for fever
• D. Flush the central line

Correct answer: A

Rationale: Monitoring the dressing site daily is crucial for detecting early signs of infection in patients with central lines. Checking for redness and swelling (choice B) is important but may indicate a more advanced stage of infection. Monitoring for fever (choice C) can also be a sign of infection, but it is a later manifestation. Flushing the central line (choice D) is necessary for maintaining patency but does not directly monitor for infection.

4. A client taking haloperidol is exhibiting extrapyramidal symptoms. Which intervention should the nurse anticipate?

• A. Increase the dose of haloperidol.
• B. Administer benztropine.
• C. Administer naloxone.
• D. Monitor blood pressure before administering the next dose.

Correct answer: B

Rationale: The correct intervention for a client exhibiting extrapyramidal symptoms while taking haloperidol is to administer benztropine. Benztropine is an anticholinergic medication commonly used to manage extrapyramidal symptoms caused by antipsychotic medications like haloperidol. Increasing the dose of haloperidol (Choice A) would exacerbate the symptoms rather than alleviate them. Administering naloxone (Choice C) is not indicated for extrapyramidal symptoms. Monitoring blood pressure (Choice D) is important but not the primary intervention for managing extrapyramidal symptoms.

5. A client is receiving opioid analgesics for pain management. Which of the following assessments is the priority?

• A. Monitor the client's blood pressure.
• B. Check the client's urinary output.
• C. Monitor the client's respiratory rate.
• D. Assess the client's pain level.

Correct answer: C

Rationale: The correct answer is C: Monitor the client's respiratory rate. When a client is receiving opioid analgesics, the priority assessment is monitoring respiratory rate. Opioids can cause respiratory depression, so it is crucial to assess the client's breathing to detect any signs of respiratory distress promptly. Checking the client's blood pressure (Choice A) and urinary output (Choice B) are important assessments too, but they are not the priority when compared to ensuring adequate respiratory function. Assessing the client's pain level (Choice D) is essential for overall care but is not the priority assessment when the client is on opioids, as respiratory status takes precedence.

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