Nursing Elites

1. The healthcare provider is assessing a client who has just undergone abdominal surgery. Which finding should be reported to the healthcare provider immediately?

• A. Absence of bowel sounds
• B. Mild abdominal distention
• C. Drainage of serosanguineous fluid from the incision
• D. Sudden onset of severe abdominal pain

Correct answer: D

Rationale: Sudden onset of severe abdominal pain may indicate complications such as peritonitis, bowel perforation, or internal bleeding. These conditions are serious and require immediate medical attention to prevent further complications or deterioration. Absence of bowel sounds, mild abdominal distention, and drainage of serosanguineous fluid are common findings after abdominal surgery and may not necessarily indicate an emergency situation requiring immediate reporting to the healthcare provider. Severe abdominal pain post-surgery should always be reported promptly as it could signify a life-threatening situation that needs urgent evaluation and intervention.

2. The nurse is providing discharge instructions to a client who had a laparoscopic cholecystectomy. What should the nurse include in the teaching?

• A. Avoid driving for at least 2 weeks
• B. Resume a low-fat diet
• C. Remove the bandages from the incision after 24 hours
• D. Expect significant pain for the first week

Correct answer: C

Rationale: The correct answer is C: 'Remove the bandages from the incision after 24 hours.' Prompt removal of bandages after 24 hours promotes proper wound healing and reduces the risk of infection. Choice A is incorrect because avoiding driving for 2 weeks may not be universally necessary post-cholecystectomy. Choice B is incorrect because while a low-fat diet is recommended after surgery, it is not directly related to incision care. Choice D is incorrect because while pain is common post-surgery, stating 'significant pain for the first week' may not apply to all patients, potentially causing unnecessary anxiety.

3. During a manic episode, what is the most appropriate intervention to implement first for a client with bipolar disorder?

• A. Engage the client in a quiet activity
• B. Provide a structured environment with minimal stimulation
• C. Monitor the client continuously
• D. Adjust the lighting and noise levels

Correct answer: B

Rationale: During a manic episode, individuals with bipolar disorder may experience sensory overload and agitation. Providing a structured environment with minimal stimulation is the most appropriate initial intervention as it can help reduce overwhelming sensory input and promote a sense of calm. Engaging the client in a quiet activity (Choice A) may not be effective if the environment is still overstimulating. Continuous monitoring (Choice C) is important but may not be the first intervention needed. Adjusting lighting and noise levels (Choice D) can be helpful but may not address the core issue of sensory overload and agitation during a manic episode.

4. The healthcare provider is providing discharge instructions to a client with chronic heart failure. Which dietary recommendation is most appropriate?

• A. Increase fluid intake.
• B. Follow a low-sodium diet.
• C. Follow a high-protein diet.
• D. Increase sodium intake.

Correct answer: B

Rationale: The most appropriate dietary recommendation for a client with chronic heart failure is to follow a low-sodium diet. This helps manage the condition by reducing fluid retention and the workload on the heart. High fluid intake can lead to fluid overload and exacerbate heart failure symptoms. While protein is important for overall health, a high-protein diet is not specifically indicated for chronic heart failure. Increasing sodium intake is contraindicated in heart failure as it can worsen fluid retention and increase the workload on the heart.

5. A client presents to the emergency department with symptoms of a myocardial infarction. What should the nurse administer immediately under doctor's orders?

• A. Aspirin to prevent further blood clotting
• B. High-flow oxygen
• C. Intravenous fluids
• D. Nitroglycerin

Correct answer: A

Rationale: The correct answer is A: Aspirin to prevent further blood clotting. Administering aspirin is crucial in the immediate management of a myocardial infarction as it helps prevent further blood clot formation, which is a key component in the treatment and prevention of myocardial infarction. Oxygen therapy (Choice B) is often provided, but aspirin takes precedence due to its role in reducing clot formation. Intravenous fluids (Choice C) may be needed but are not the immediate priority in this situation. Nitroglycerin (Choice D) is commonly used for chest pain relief in myocardial infarction but is not the first medication to be administered in this scenario.

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