Nursing Elites

1. The nurse is caring for the client recovering from intestinal surgery. Which assessment finding would require immediate intervention?

• A. Presence of thin pink drainage in the Jackson Pratt
• B. Guarding when the nurse touches the abdomen
• C. Tenderness around the surgical site during palpation
• D. Complaints of chills and feeling feverish

Correct answer: D

Rationale: Complaints of chills and feeling feverish may indicate infection, which requires immediate intervention. This finding suggests a systemic response to infection, which can be life-threatening if not promptly addressed. Options A, B, and C are common postoperative findings and may not necessarily require immediate intervention unless accompanied by other concerning signs or symptoms.

2. The nurse is teaching the client diagnosed with colon cancer who is scheduled for a colostomy the next day. Which behavior indicates the best method of applying adult teaching principles?

• A. The nurse repeats the information as indicated by the client’s questions
• B. The nurse teaches all the information needed by the client in one session
• C. The nurse uses a video to explain with medical terms to the client
• D. The nurse waits until the client asks questions about the surgery

Correct answer: A

Rationale: Choice A is the best method of applying adult teaching principles because repeating information and addressing the client’s questions as they arise is effective for reinforcing learning in adults. This approach allows for clarification of doubts and ensures that the client understands the information provided. Choice B is incorrect as teaching all the information in one session may overwhelm the client and hinder retention. Choice C is incorrect as using medical terms without ensuring the client's understanding may lead to confusion. Choice D is incorrect because waiting for the client to ask questions may result in missed opportunities to address important information proactively.

3. When assessing the integumentary system of a client with anorexia nervosa, which finding would support the diagnosis?

• A. Preoccupation with calories
• B. Thick body hair
• C. Sore tongue
• D. Dry, brittle hair

Correct answer: D

Rationale: The correct answer is D: Dry, brittle hair. Dry, brittle hair is a common sign of malnutrition, often seen in clients with anorexia nervosa. Preoccupation with calories (choice A) is more related to the psychological aspect of anorexia rather than a physical finding. Thick body hair (choice B) is not typically associated with anorexia nervosa. A sore tongue (choice C) can be seen in conditions like vitamin deficiencies or oral health issues but is not specific to anorexia nervosa.

4. When is aspirin most effective when taken?

• A. On an empty stomach with cold water
• B. On a full stomach after a meal
• C. With a glass of fruit juice
• D. First thing in the morning

Correct answer: A

Rationale: Aspirin is best absorbed on an empty stomach to maximize its effectiveness. Taking it with cold water helps in its quick absorption. Option B is incorrect because taking aspirin on a full stomach can delay its absorption. Option C is incorrect as fruit juice may not provide the ideal conditions for absorption. Option D is incorrect as taking aspirin first thing in the morning may not ensure an empty stomach.

5. Which discharge instruction should the nurse teach the client diagnosed with varicose veins who has received sclerotherapy?

• A. Walk 15 to 20 minutes three (3) times a day.
• B. Keep the legs in the dependent position when sitting.
• C. Remove compression bandages before going to bed.
• D. Perform Berger-Allen exercises (4) times a day.

Correct answer: A

Rationale: The correct answer is to instruct the client to walk 15 to 20 minutes three times a day. Walking is beneficial as it helps improve circulation and reduces the risk of complications following sclerotherapy. Choice B is incorrect because keeping the legs in the dependent position when sitting can lead to increased venous pressure, worsening varicose veins. Choice C is incorrect as compression bandages should typically be worn continuously, especially during the initial healing phase. Choice D is incorrect as Berger-Allen exercises are not commonly associated with post-sclerotherapy care.

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