Nursing Elites

1. The nurse is caring for the client one (1) day postoperative sigmoid colostomy operation. Which independent nursing intervention should the nurse implement?

• A. Change the infusion rate of the intravenous fluid
• B. Encourage the client to discuss his or her feelings
• C. Administer opioid narcotic medications for pain management
• D. Assist the client out of bed to sit in the chair twice daily

Correct answer: D

Rationale: Assisting the client to sit in a chair is a crucial nursing intervention postoperatively. It helps prevent complications such as thrombosis, pneumonia, and pressure ulcers by promoting circulation and aiding in recovery. Changing the infusion rate of the intravenous fluid would require a physician's order and is not within the nurse's independent scope of practice. Encouraging the client to discuss feelings and administering medications for pain management are important interventions but may not be as immediately necessary as assisting the client in mobilizing early postoperatively.

2. The client is diagnosed with pericarditis. When assessing the client, the nurse is unable to auscultate a friction rub. Which action should the nurse implement?

• A. Notify the healthcare provider
• B. Document that the pericarditis has resolved
• C. Ask the client to lean forward and listen again
• D. Prepare to insert a unilateral chest tube

Correct answer: C

Rationale: The correct action for the nurse to implement when unable to auscultate a pericardial friction rub in a client diagnosed with pericarditis is to ask the client to lean forward and listen again. Leaning forward can help bring the heart closer to the chest wall, making it easier to detect the rub. Option A (Notifying the healthcare provider) is incorrect because further assessment is needed before escalating the situation. Option B (Documenting that the pericarditis has resolved) is incorrect as the absence of a friction rub does not necessarily mean resolution. Option D (Preparing to insert a unilateral chest tube) is incorrect as this intervention is not indicated for the absence of a friction rub.

3. The nurse is preparing the plan of care for a client with fluid volume deficit. Which interventions should the nurse include in the plan of care?

• A. Monitor vital signs every two (2) hours until stable
• B. Weigh the client in the same clothing at the same time daily
• C. Administer mouth care every eight (8) hours
• D. A, B, and C

Correct answer: D

Rationale: The correct interventions for a client with fluid volume deficit include monitoring vital signs every two hours until stable, weighing the client in the same clothing at the same time daily, and assessing skin turgor. Monitoring vital signs helps in early detection of changes, daily weighing can indicate fluid retention or loss, and skin turgor assessment is a reliable indicator of hydration status. Administering mouth care every eight hours is not directly related to managing fluid volume deficit and should not be included in the plan of care for this specific condition.

4. A client has been given instructions about ferrous sulfate. Which statement made by the client would indicate the client needs further education?

• A. "I will take this medication with a full glass of milk."
• B. "I will take the morning dose 1 hour before breakfast."
• C. "I will need to avoid taking this medication with coffee."
• D. "I will take antacids if needed, 2 hours after I take ferrous sulfate."

Correct answer: A

Rationale: The correct answer is A. Ferrous sulfate should not be taken with milk as it can impair iron absorption. Choice B is correct as taking the morning dose 1 hour before breakfast is appropriate. Choice C is correct as coffee can interfere with iron absorption. Choice D is correct as antacids should be taken 2 hours after ferrous sulfate to avoid interference with its absorption.

5. Which signs/symptoms would the nurse expect to find in the client diagnosed with an insulinoma?

• A. Nervousness, jitteriness, and diaphoresis
• B. Flushed skin, dry mouth, and tented skin turgor
• C. Polyuria, polydipsia, polyphagia
• D. Hypertension, tachycardia, and feeling hot

Correct answer: A

Rationale: Corrected Rationale: Insulinomas lead to excessive insulin production, causing hypoglycemia. Symptoms of hypoglycemia include nervousness, jitteriness, and diaphoresis. These symptoms result from the low blood sugar levels. Flushed skin, dry mouth, and tented skin turgor (choice B) are more indicative of dehydration. Polyuria, polydipsia, and polyphagia (choice C) are classic symptoms of diabetes mellitus, not insulinomas. Hypertension, tachycardia, and feeling hot (choice D) are not typical symptoms of insulinomas.

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