Nursing Elites

1. The healthcare professional is assessing a client who is post-operative following abdominal surgery. Which assessment finding would require immediate intervention?

• A. Absent bowel sounds
• B. Pain level of 8/10
• C. Temperature of 100.4°F
• D. Saturated abdominal dressing

Correct answer: D

Rationale: A saturated abdominal dressing may indicate active bleeding or other complications that require immediate intervention. This finding suggests a potential surgical site issue that needs urgent attention to prevent further complications. Absent bowel sounds, pain level, and a slightly elevated temperature are common post-operative findings that may not necessarily require immediate intervention compared to a saturated abdominal dressing. Absent bowel sounds can be common after surgery due to anesthesia but may resolve with time. Pain and slightly elevated temperature are expected post-operative findings that can be managed with appropriate pain relief and monitoring. However, a saturated abdominal dressing indicates a potential ongoing issue at the surgical site that needs prompt assessment and intervention to prevent complications.

2. A charge nurse is observing a newly licensed nurse prepare a sterile field. Which of the following actions should the charge nurse identify as contaminating the sterile field?

• A. The nurse opens the sterile field on a wet surface.
• B. The nurse turns away from the sterile field.
• C. The nurse uses a non-sterile glove to touch the sterile field.
• D. The nurse touches the edge of the sterile drape with her hand.

Correct answer: A

Rationale: The correct answer is A. Opening the sterile field on a wet surface contaminates it, rendering it unsafe for use. Moisture can carry microorganisms that can compromise the sterility of the field. Choice B is incorrect because turning away from the sterile field alone does not necessarily contaminate it unless the nurse touches non-sterile items. Choice C is incorrect because using a non-sterile glove to touch the sterile field directly introduces contaminants. Choice D is incorrect as touching the edge of the sterile drape with a hand may not necessarily contaminate the entire field, unlike opening it on a wet surface.

3. A client asks about the purpose of advance directives. Which of the following statements should the nurse make?

• A. They allow the court to overrule an adult client's refusal of medical treatment.
• B. They indicate the form of treatment a client is willing to accept in the event of a serious illness.
• C. They permit a client to withhold medical information from health care personnel.
• D. They allow health care personnel in the emergency department to stabilize a client's condition.

Correct answer: B

Rationale: The correct answer is B. Advance directives specify the type of medical treatment a client wishes to receive or avoid in the event of a serious illness. Choice A is incorrect because advance directives do not allow the court to overrule a client's refusal of medical treatment; they empower the client to make their own healthcare decisions. Choice C is incorrect because advance directives do not permit a client to withhold medical information; they provide guidance on the client's treatment preferences. Choice D is incorrect because advance directives do not specifically address the actions of health care personnel in the emergency department; they focus on the client's treatment preferences in general.

4. The patient has been in bed for several days and needs to be ambulated. Which action will the nurse take first?

• A. Maintain a narrow base of support.
• B. Dangle the patient at the bedside.
• C. Encourage isometric exercises.
• D. Suggest a high-calcium diet.

Correct answer: B

Rationale: The correct action the nurse should take first when a patient needs to be mobilized after being in bed for several days is to dangle the patient at the bedside. Dangling at the bedside is the initial step to assess the patient's tolerance to sitting up and moving. It helps prevent orthostatic hypotension and allows the nurse to evaluate the patient's response to upright positioning before attempting further ambulation. Maintaining a narrow base of support (Choice A) is related to assisting with ambulation but is not the first step. Encouraging isometric exercises (Choice C) and suggesting a high-calcium diet (Choice D) are not immediate actions needed to initiate mobilization in this scenario.

5. A client is admitted with a diagnosis of septicemia. Which assessment finding should the LPN/LVN report to the healthcare provider immediately?

• A. Increased urine output
• B. Decreased blood pressure
• C. Increased heart rate
• D. Increased respiratory rate

Correct answer: B

Rationale: In a client with septicemia, decreased blood pressure is a critical finding that suggests potential septic shock, a life-threatening condition. Septic shock requires immediate medical intervention to prevent further deterioration and organ dysfunction. Increased urine output (Choice A) may indicate adequate fluid resuscitation, which is a positive response. Increased heart rate (Choice C) and increased respiratory rate (Choice D) are common physiological responses to sepsis and do not necessarily indicate immediate life-threatening complications like decreased blood pressure does in septic shock.

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