Nursing Elites

1. A postoperative client has been diagnosed with paralytic ileus. When performing auscultation of the client’s abdomen, the nurse expects the bowel sounds to be:

• A. Absent
• B. Hyperactive
• C. Normal
• D. Hypoactive

Correct answer: A

Rationale: In paralytic ileus, bowel sounds are typically absent or significantly reduced due to decreased motility of the intestines. This absence of bowel sounds is a key characteristic used in diagnosing paralytic ileus. Hyperactive bowel sounds are not expected in this condition as there is a lack of normal peristalsis. Normal bowel sounds would not be present in paralytic ileus, and hypoactive bowel sounds, which indicate decreased bowel motility, are more commonly associated with conditions like postoperative ileus or constipation, rather than paralytic ileus.

2. A child is postoperative following a tonsillectomy. Which of the following actions should the nurse take?

• A. Administer analgesics to the child on a routine schedule throughout the day and night.
• B. Offer fluids to the child immediately after surgery.
• C. Allow the child to return to solid foods gradually.
• D. Avoid administering any medication until the child is fully awake.

Correct answer: A

Rationale: Administering analgesics to the child on a routine schedule throughout the day and night is crucial for managing postoperative pain effectively and ensuring the child's comfort. Pain management is a priority in the postoperative period to promote healing and prevent complications. Offering fluids to the child immediately after surgery (Choice B) is essential to prevent dehydration, but pain control takes precedence. Allowing the child to return to solid foods gradually (Choice C) is important, but initially, the child may need to start with clear liquids and progress to soft foods post-tonsillectomy. Avoiding administering any medication until the child is fully awake (Choice D) is not advisable because timely pain relief is essential for the child's comfort and recovery.

3. A client who has been experiencing frequent tonic-clonic seizures is being admitted by a nurse. Which of the following actions should the nurse include in the client's plan of care?

• A. Wrap blankets around all four sides of the bed.
• B. Place the client in a padded room.
• C. Maintain the bed in the lowest position.
• D. Ensure the client has a soft mattress.

Correct answer: C

Rationale: Maintaining the bed in the lowest position is crucial in reducing the risk of injury during tonic-clonic seizures. This action helps prevent falls and minimizes potential harm to the client. Wrapping blankets around all four sides of the bed (Choice A) may restrict movement during a seizure and increase the risk of injury. Placing the client in a padded room (Choice B) is not a practical approach in a healthcare setting and may not be feasible. Ensuring the client has a soft mattress (Choice D) alone does not address the safety concerns during seizures, unlike keeping the bed in the lowest position.

4. The nurse manager is reviewing medication documentation. Which of the following statements should the nurse plan to include in teaching?

• A. Use the complete name of the medication magnesium sulfate.
• B. Avoid abbreviating medication names to prevent errors.
• C. Use generic names only for medications.
• D. Document the dosage, route of administration, and complete medication name.

Correct answer: A

Rationale: The correct answer is A: 'Use the complete name of the medication magnesium sulfate.' When documenting medications, it is crucial to use the complete name to avoid confusion and errors. Abbreviating medication names (choice B) can lead to misinterpretation and errors in medication administration. Using generic names only for medications (choice C) may not provide enough specificity, leading to potential medication errors. While documenting the dosage and route of administration is important, it is also vital to include the complete medication name (choice D) for accurate record-keeping and to ensure clarity in medication administration.

5. A patient has been diagnosed with osteoporosis and lactose intolerance. What intervention will the nurse implement?

• A. Encourage dairy alternatives.
• B. Monitor intake of vitamin D.
• C. Increase intake of caffeinated drinks.
• D. Assist the patient with daily activities.

Correct answer: B

Rationale: The correct intervention for a patient diagnosed with osteoporosis and lactose intolerance is to monitor their intake of vitamin D. Since the patient has lactose intolerance, encouraging dairy alternatives (Choice A) would not be appropriate. Increasing intake of caffeinated drinks (Choice C) is not beneficial for managing osteoporosis and may even have negative effects on bone health. Assisting the patient with daily activities (Choice D) is a general nursing intervention that may not directly address the specific needs related to osteoporosis and lactose intolerance.

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