Nursing Elites

1. A post-operative client with a sutured abdominal incision felt a sharp abdominal pain after having a bowel movement. Upon inspection, the nurse notices bowel protruding from the incision site. What does the nurse tell the physician about the event?

• A. The client's incision site has eviscerated
• B. The client's incision site has lacerated
• C. The client's incisional site is approximated
• D. The client's incisional site has dehisced after.

Correct answer: A

Rationale:

2. A client states that he has been experiencing oozing from his wounds. What is the nurse's priority action?

• A. Insert the wound and assess the drainage
• B. Apply topical ointment to the wound
• C. Call the provider to initiate antibiotics
• D. Culture the wound

Correct answer: D

Rationale:

3. Which of the following clients should be placed in isolation for airborne precautions?

• A. A high school wrestling championship with a rash
• B. A client that recently travelled and developed a fever with cough
• C. A client with an unknown skin infection
• D. A client with heart palpitations

Correct answer: B

Rationale:

4. The goal for a client with impaired mobility is to prevent atelectasis. What nursing intervention would best help the client meet this goal?

• A. Assist the client to orthopneic position
• B. Offer a protein-rich diet
• C. Offer the client a bedpan for toileting
• D. Turn the client every 4 hours

Correct answer: A

Rationale: Assisting the client to the orthopneic position is the best nursing intervention to help prevent atelectasis. This position improves lung expansion by allowing the chest to expand fully, aiding in the prevention of atelectasis. Offering a protein-rich diet (choice B) is important for overall nutrition but does not directly address preventing atelectasis. Offering a bedpan for toileting (choice C) and turning the client every 4 hours (choice D) are important for preventing pressure ulcers in immobile clients but do not directly prevent atelectasis.

5. The nurse suspects a 3-year-old who is coughing vigorously has aspirated a small object. Which action should the nurse take?

• A. Deliver upward abdominal thrusts with a fisted hand
• B. Perform a blind finger sweep of the child's mouth
• C. Complete five rapid back blows between the shoulder blades
• D. Encourage the child to continue coughing

Correct answer: D

Rationale:

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