Nursing Elites

1. The client had gastric bypass surgery yesterday. Which intervention is most important for the nurse to implement during the first 24 postoperative hours?

• A. Insert an indwelling urinary catheter
• B. Monitor for the appearance of an incisional hernia
• C. Instruct the client to eat small frequent meals
• D. Measure hourly urinary output

Correct answer: D

Rationale: Monitoring hourly urinary output is crucial during the first 24 postoperative hours to assess kidney function, fluid balance, and early detection of complications like dehydration or inadequate kidney perfusion. Inserting an indwelling urinary catheter is not routinely necessary after gastric bypass surgery unless there are specific indications. Monitoring for an incisional hernia is important but not the highest priority in the immediate postoperative period. Instructing the client to eat small frequent meals is essential for long-term dietary management after gastric bypass surgery, but not the most critical intervention during the initial 24 hours.

2. A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely?

• A. Hypokalemia
• B. Ketonuria
• C. Peripheral edema
• D. Elevated blood pressure

Correct answer: A

Rationale: The correct answer is A: Hypokalemia. In diabetes insipidus, there is excessive urination leading to fluid loss, which can result in electrolyte imbalances such as hypokalemia. Monitoring potassium levels is crucial to prevent complications like cardiac arrhythmias. Choices B, C, and D are incorrect. Ketonuria is typically seen in diabetic ketoacidosis, peripheral edema is more commonly associated with conditions like heart failure or kidney disease, and elevated blood pressure is not a direct complication of diabetes insipidus related to a pituitary gland tumor.

3. An older client comes to the clinic with a family member. When the nurse attempts to take the client’s health history, the client does not respond to questions clearly. What action should the nurse implement first?

• A. Assess the surroundings for noise and distractions
• B. Provide a printed health history form
• C. Defer the health history until the client is less anxious
• D. Ask the family member to answer the questions

Correct answer: A

Rationale: The correct action for the nurse to implement first is to assess the surroundings for noise and distractions. This step is crucial as environmental factors can affect the client's ability to respond clearly. By minimizing noise and distractions, the nurse can create a more conducive environment for effective communication. Providing a printed form (Choice B) may help but addressing environmental factors should come first. Deferring the health history (Choice C) or asking the family member to answer the questions (Choice D) should not be the initial steps, as they do not directly address the issue of unclear communication with the client.

4. A client with a BMI of 60.2 kg/m² is admitted to the intensive care unit 3 weeks after gastric bypass with gastric rupture and impending multiple organ dysfunction syndrome (MODS). What should the nurse prepare to implement first?

• A. Mechanical ventilation
• B. Platelet transfusion
• C. Loop diuretic therapy
• D. Cyanocobalamin administration

Correct answer: A

Rationale: In this critical situation with gastric rupture and impending MODS, the priority intervention should be mechanical ventilation. This client is at risk of respiratory compromise due to the severity of the condition. Platelet transfusion (Choice B) is not the priority as there is no indication of significant bleeding. Loop diuretic therapy (Choice C) and cyanocobalamin administration (Choice D) are not the immediate priorities in this scenario and would not address the urgent need for respiratory support.

5. When administering diazepam, a benzodiazepine, 10 mg IV push PRN for a client with alcohol withdrawal symptoms, which actions should the nurse implement? (Select all that apply)

• A. Protect the medication from light exposure
• B. Monitor for changes in level of consciousness
• C. Observe for onset of generalized bruising or bleeding
• D. Perform ongoing assessment of respiratory status

Correct answer: D

Rationale: When administering diazepam for a client with alcohol withdrawal symptoms, it is crucial to perform ongoing assessment of respiratory status. Diazepam can lead to respiratory depression, emphasizing the need for continuous monitoring to detect any signs of respiratory distress early. Protecting the medication from light exposure is a general guideline for some drugs but is not a specific concern for diazepam. Observing for bruising or bleeding is not directly associated with the administration of diazepam for alcohol withdrawal symptoms, making choices A and C incorrect.

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