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. Which vitamin deficiency is commonly associated with prolonged antibiotic use?

• A. Vitamin A
• B. Vitamin B6
• C. Vitamin C
• D. Vitamin K

Correct answer: D

Rationale: The correct answer is Vitamin K. Prolonged antibiotic use can disrupt the gut flora, which is responsible for synthesizing Vitamin K. This disruption can lead to a Vitamin K deficiency and an increased risk of bleeding. Vitamin A, B6, and C deficiencies are not typically associated with prolonged antibiotic use.

3. Warfarin (Coumadin) is an anticoagulant and interferes with the action of:

• A. Platelets
• B. Vitamin K
• C. Calcium
• D. Vitamin B12

Correct answer: B

Rationale: The correct answer is B: Vitamin K. Warfarin inhibits the action of vitamin K, which is essential for blood clotting. By interfering with the production of certain clotting factors, warfarin helps prevent blood clots. Choices A, C, and D are incorrect because warfarin primarily affects the vitamin K-dependent clotting factors and not platelets, calcium, or vitamin B12.

4. The nurse has given post-procedure instructions to a client who underwent a colonoscopy. Evaluation of learning would be evident if the client makes which statement(s)?

• A. All of the above
• B. “My abdominal muscles may be tender because of the procedure.”
• C. “My diet should be light at first, and then I can progress to a regular diet.”
• D. “It is normal to feel gassy or bloated for a short while after the procedure.”

Correct answer: A

Rationale: The correct answer is A: "All of the above." Evaluation of learning after a colonoscopy would be evident if the client mentions all the statements provided. Mild tenderness in the abdominal muscles, starting with a light diet and progressing to a regular diet, and experiencing gas or bloating temporarily are all expected after a colonoscopy. Therefore, all the statements are correct in demonstrating the client's understanding of the post-procedure instructions. Choices B, C, and D provide accurate information about the expected outcomes following a colonoscopy, making them incorrect answers individually but correct when combined as option A.

5. The client diagnosed with acute pancreatitis has developed a pseudocyst that ruptures. Which procedure should the nurse anticipate the HCP ordering?

• A. Paracentesis
• B. Chest tube insertion
• C. Lumbar puncture
• D. Biopsy of the pancreas

Correct answer: B

Rationale: The correct answer is B: Chest tube insertion. In the context of a pancreatic pseudocyst rupturing, a chest tube may be needed if the pseudocyst extends into the pleural space, leading to a pleural effusion. Choice A, paracentesis, involves the removal of fluid from the abdominal cavity, not the pleural space. Choice C, lumbar puncture, is a procedure performed to collect cerebrospinal fluid from the spinal canal, not relevant in this scenario. Choice D, biopsy of the pancreas, is not indicated in the immediate management of a ruptured pseudocyst.

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