Nursing Elites

1. Which finding is most important for the nurse to communicate to the health care provider about a patient who received a liver transplant 1 week ago?

• A. Dry palpebral and oral mucosa
• B. Crackles at bilateral lung bases
• C. Temperature 100.8?F (38.2?C)
• D. No bowel movement for 4 days

Correct answer: C

Rationale: The correct answer is the patient's temperature of 100.8�F (38.2�C). In a patient who received a liver transplant 1 week ago, a fever is a significant finding that should be promptly communicated to the health care provider. Post-transplant patients are at high risk of infections, and fever can often be the initial indicator of an underlying infectious process. The other findings listed in choices A, B, and D are important and should be addressed, but they do not take precedence over a potential infection post-liver transplant. Dry palpebral and oral mucosa may indicate dehydration, crackles at bilateral lung bases may suggest fluid overload or infection, and no bowel movement for 4 days could indicate a bowel obstruction or ileus. However, in the context of a recent liver transplant, an elevated temperature is the most concerning and requires immediate attention to rule out infection.

2. After surgery for an imperforate anus, an infant returns with a red and edematous colostomy stoma. What action should the nurse take based on this finding?

• A. Elevate the buttocks.
• B. Document the findings.
• C. Apply ice immediately.
• D. Call the primary health care provider.

Correct answer: B

Rationale: A red and edematous colostomy stoma is a common finding immediately after surgery, and these changes are expected to decrease over time. As the stoma heals, it usually becomes pink without signs of abnormal drainage, swelling, or skin breakdown. Therefore, the appropriate action for the nurse is to document these normal findings. Elevating the buttocks, applying ice, or calling the primary health care provider are unnecessary interventions at this stage.

3. What nursing intervention demonstrates that the nurse understands the priority nursing diagnosis when caring for oral cancer patients with extensive tumor involvement and/or a high amount of secretions?

• A. The nurse uses a pen pad to communicate with the patient
• B. The nurse provides oral care every 2 hours
• C. The nurse listens for bowel sounds every 4 hours
• D. The nurse suctions as needed and elevates the head of the bed

Correct answer: D

Rationale: The correct answer is to suction as needed and elevate the head of the bed. This intervention is crucial for managing Ineffective Airway Clearance, which is the priority nursing diagnosis in oral cancer patients with extensive tumor involvement and/or a high amount of secretions. Suctioning helps clear secretions that may obstruct the airway, while elevating the head of the bed promotes optimal respiratory function. Providing oral care every 2 hours may be important for overall oral health but is not directly related to addressing the priority diagnosis. Listening for bowel sounds every 4 hours is more relevant to gastrointestinal assessment and not specific to managing airway clearance issues in oral cancer patients.

4. When obtaining a health history and physical assessment for a 36-year-old female patient with possible multiple sclerosis (MS), the nurse should

• A. assess for the presence of chest pain.
• B. inquire about urinary tract problems.
• C. inspect the skin for rashes or discoloration.
• D. ask the patient about any increase in libido.

Correct answer: B

Rationale: When assessing a patient for possible multiple sclerosis (MS), it is important to inquire about urinary tract problems as they are common symptoms of the condition, such as incontinence or retention. Chest pain is not typically associated with MS, so assessing for its presence is not a priority. Inspecting the skin for rashes or discoloration is not a typical manifestation of MS. Additionally, a decrease in libido, rather than an increase, is more commonly seen in patients with MS. Therefore, the most appropriate action for the nurse in this scenario is to inquire about urinary tract problems.

5. An infant has just returned to the nursing unit after surgical repair of a cleft lip on the right side. The nurse should place the infant in which best position at this time?

• A. Prone position
• B. On the stomach
• C. Left lateral position
• D. Right lateral position

Correct answer: C

Rationale: After surgical repair of a cleft lip on the right side, the nurse should position the infant carefully to ensure comfort and prevent complications. Placing the infant in the prone position or on the stomach is not recommended as it may cause rubbing of the surgical site against the mattress. The optimal position for the infant is the left lateral position, away from the surgical repair site, to minimize the risk of trauma. Placing the infant on the right lateral position would be contraindicated as it is on the side of the repair. Additionally, positioning the infant upright on the back can help prevent airway obstruction by secretions, blood, or the tongue. Therefore, the correct choice is to place the infant in the left lateral position to promote safety and comfort post cleft lip surgery.

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