Nursing Elites

1. Which documentation indicates that activities to prevent postoperative venous stasis were performed correctly?

• A. Antiembolism stockings on, leg exercises performed hourly.
• B. Antiembolism stockings removed hourly during leg exercises.
• C. Leg exercises not performed due to antiembolism hose.
• D. Client demonstrates ability to move extremities well.

Correct answer: A

Rationale: The correct answer is A: 'Antiembolism stockings on, leg exercises performed hourly.' This documentation indicates the correct performance of activities to prevent postoperative venous stasis, as both components are crucial for prevention. Choice B is incorrect because removing stockings hourly is not recommended. Choice C is incorrect as leg exercises should be performed despite wearing antiembolism stockings. Choice D is incorrect as demonstrating the ability to move extremities well does not specifically address the prevention of venous stasis.

2. A client with a ruptured spleen underwent an emergency splenectomy. Twelve hours later, the client’s urine output is 25 ml/hour. What is the most likely cause?

• A. This is a normal finding after surgery.
• B. Oliguria signals tubular necrosis related to hypoperfusion.
• C. Oliguria signals dehydration and fluid loss.
• D. Urine output of 25 ml/hour is an expected finding after splenectomy.

Correct answer: B

Rationale: Oliguria, or decreased urine output, after surgery can indicate tubular necrosis due to hypoperfusion, which may require intervention to restore renal function. Choice A is incorrect as oliguria is not a normal finding after surgery. Choice C is incorrect because dehydration is less likely in this context compared to tubular necrosis. Choice D is incorrect as a urine output of 25 ml/hour is not expected after splenectomy and should raise concern for renal impairment.

3. A client with a peripherally inserted central catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform?

• A. Inspect the PICC insertion site for signs of infection.
• B. Observe the antecubital fossa for inflammation.
• C. Auscultate lung sounds for signs of respiratory distress.
• D. Check for signs of phlebitis or thrombosis along the catheter site.

Correct answer: B

Rationale: Observing the antecubital fossa for inflammation is crucial in clients with a PICC line and fever. Inflammation at the site can indicate infection or complications related to the PICC line. Auscultating lung sounds (choice C) is important but not the priority in this situation. Checking for phlebitis or thrombosis (choice D) is relevant but does not address the immediate concern of identifying infection or complications at the insertion site. Inspecting the PICC insertion site (choice A) is also important but observing the antecubital fossa provides a more direct assessment of potential issues with the PICC line.

4. A client is admitted with an epidural hematoma after a skateboarding accident. How should the nurse differentiate the vascular source of intracranial bleeding?

• A. Monitor for clear fluid leakage from the nose.
• B. Assess for rapid onset of decreased level of consciousness.
• C. Check for bruising around the head and neck.
• D. Assess for changes in pupil size and reactivity.

Correct answer: B

Rationale: An epidural hematoma is characterized by a rapid onset of symptoms, including decreased level of consciousness, due to arterial bleeding, which differentiates it from other types of intracranial hemorrhage. Monitoring for clear fluid leakage from the nose (choice A) is more indicative of a basilar skull fracture and cerebrospinal fluid leak. Checking for bruising around the head and neck (choice C) is more suggestive of soft tissue injuries or facial fractures. Assessing for changes in pupil size and reactivity (choice D) is essential in evaluating traumatic brain injuries, but it is not specific to differentiating the vascular source of intracranial bleeding in an epidural hematoma.

5. A client with diabetes mellitus presents with a blood sugar level of 320 mg/dL. What is the nurse's initial action?

• A. Administer sliding scale insulin as prescribed
• B. Encourage the client to drink fluids
• C. Provide the client with a carbohydrate snack
• D. Assess the client for signs of hypoglycemia

Correct answer: A

Rationale: When a client with diabetes mellitus presents with a high blood sugar level of 320 mg/dL, the nurse's initial action should be to administer sliding scale insulin as prescribed. The priority is to bring down the elevated glucose level promptly to prevent further complications. Encouraging the client to drink fluids or providing a carbohydrate snack would not effectively address the elevated blood sugar level in this scenario. Assessing for signs of hypoglycemia is not appropriate as the client's blood sugar level is high, not low.

Similar Questions