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. The nurse is evaluating a client who has had a mastectomy and is experiencing pain and swelling in the arm on the affected side. What action should the nurse take?

• A. Assess for signs of lymphedema
• B. Encourage the client to perform arm exercises
• C. Provide pain relief through medication
• D. Recommend wearing a compression sleeve

Correct answer: A

Rationale: Assessing for signs of lymphedema is crucial in this situation as it is a common complication following mastectomy. Lymphedema presents as swelling and pain in the affected arm due to compromised lymphatic drainage. By assessing for lymphedema, the nurse can identify the condition early and implement appropriate interventions such as compression sleeves, manual lymphatic drainage, and exercises. Encouraging arm exercises (Choice B) may exacerbate the symptoms if lymphedema is present. While providing pain relief through medication (Choice C) is important, assessing for the underlying cause of pain and swelling takes precedence. Recommending a compression sleeve (Choice D) may be suitable but should come after a thorough assessment for lymphedema to ensure the most effective management plan.

3. When assessing a client with acute asthma, the nurse is most likely to obtain which finding?

• A. Pursed lip breathing and clubbing of fingers
• B. Fever and a high-pitched inspiratory stridor
• C. A short expiratory phase and hemoptysis
• D. Cough and musical breath sounds on expiration

Correct answer: D

Rationale: When assessing a client with acute asthma, a cough and wheezing or musical breath sounds on expiration are typical findings. Pursed lip breathing and clubbing of fingers (choice A) are not common in acute asthma but could be seen in chronic respiratory conditions. Fever and high-pitched inspiratory stridor (choice B) are more indicative of croup or epiglottitis. A short expiratory phase and hemoptysis (choice C) are not typical findings in acute asthma.

4. A woman at 24-weeks gestation who has fever, body aches, and has been coughing for the last 5 days is sent to the hospital with admission prescriptions for H1N1 influenza. Which action has the highest priority?

• A. Administer Ringer's Lactate IV 125ml/8 hours
• B. Obtain specimens for cultures
• C. Assign a private room
• D. Monitor vital signs q4 hours

Correct answer: C

Rationale: Assigning a private room has the highest priority in this scenario. It helps prevent the spread of H1N1 influenza to other patients and protects both the patient and others from potential infection. Obtaining specimens for cultures and monitoring vital signs are important but do not address the immediate need to prevent the spread of the virus. Administering Ringer's Lactate IV is not the priority in this case as it does not directly address the infectious nature of the condition.

5. The nurse is assessing an older adult with type 2 diabetes. Which assessment finding indicates that the client understands long-term control of diabetes?

• A. The fasting blood sugar was 120 mg/dL this morning
• B. Urine ketones have been negative for the past 6 months
• C. The hemoglobin A1C was 6.5% last week
• D. No diabetic ketoacidosis has occurred in 6 months

Correct answer: C

Rationale: An A1C level of 6.5% indicates good long-term control of diabetes as it reflects the average blood sugar levels over the past 2-3 months. Monitoring fasting blood sugar provides immediate information about the current blood sugar level, while the absence of urine ketones indicates short-term control. Although the absence of diabetic ketoacidosis is positive, it doesn't specifically reflect long-term control like the A1C level does.

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