Nursing Elites

1. The client has been diagnosed with hemorrhoids. Which statement from the client indicates that further teaching is needed?

• A. “I should increase fruits, bran, and fluids in my diet.”
• B. “I will use warm compresses and take sitz baths daily.”
• C. “I must take a laxative every night and have a stool daily.”
• D. “I can use an analgesic ointment or suppository for pain.”

Correct answer: C

Rationale: Choice C indicates that further teaching is needed because taking a laxative every night and aiming to have a stool daily can lead to dependence and is not recommended for managing hemorrhoids. Choices A, B, and D are appropriate self-care measures for hemorrhoids, such as increasing fiber intake, using warm compresses/sitz baths, and using analgesic ointments or suppositories for pain relief.

2. For which client situation would a consultation with a rapid response team (RRT) be most appropriate?

• A. 45-year-old; 2 years post kidney transplant; second hospital day for treatment of pneumonia; no urine output for 6 hours; temperature 101.4°F; heart rate of 98 beats per minute; respirations 20 breaths per minute; blood pressure 88/72 mm Hg; is restless
• B. 72-year-old; 24 hours after removal of a chest tube that was used to drain pleural fluid (effusion); temperature 97.8°F; heart rate 92 beats per minute; respirations 28 breaths per minute; blood pressure 132/86 mm Hg; anxious about going home
• C. 56-year-old fourth hospital day after a coronary artery bypass procedure; sore chest; pain with walking temperature 97°F; heart rate 84 beats per minute; respirations 22 breaths per minute; blood pressure 87/72 mm Hg; bored with hospitalization.
• D. 86-year-old; 48 hours postoperative repair of a fractured hip (nail inserted; alert; oriented; using patient-controlled analgesia (PCA) pump; temperature 96.8°F; heart rate 60 beats per minute; respirations 16 breaths per minute; blood pressure 90/62 mm Hg; talking with daughter.

Correct answer: A

Rationale: A consultation with a Rapid Response Team (RRT) is most appropriate for the 45-year-old client described in Choice A. This client is 2 years post kidney transplant, presenting with no urine output for 6 hours, a temperature of 101.4°F, heart rate of 98 beats per minute, respirations of 20 breaths per minute, and a blood pressure of 88/72 mm Hg, along with restlessness. These clinical signs are indicative of possible acute renal failure and sepsis, requiring immediate intervention by the rapid response team. Choices B, C, and D do not present the same level of urgency and severity of symptoms as the client in Choice A, making them less appropriate for consultation with the RRT.

3. The system used at the division level and forward comprises six basic modules. Which module is composed of practical nurses, medical specialists, and equipment to provide medical support for minimal care patients?

• A. Treatment squad
• B. Patient holding squad
• C. Area support squad
• D. Surgical squad

Correct answer: B

Rationale: The Patient Holding Squad is the module composed of practical nurses, medical specialists, and equipment to provide medical support for minimal care patients. The other choices are incorrect because a 'Treatment squad' would typically involve a broader range of medical care, an 'Area support squad' is more general and focuses on providing overall support in a specific area, and a 'Surgical squad' would be specifically focused on surgical procedures rather than general medical care for minimal care patients.

4. A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client’s fluid status?

• A. Measuring and recording fluid intake and output
• B. Weighing the client daily at the same time each day
• C. Assessing the client’s vital signs every 4 hours
• D. Checking the client’s lungs for crackles during every shift

Correct answer: B

Rationale: The correct answer is B. Weighing the client daily at the same time each day is the most accurate method for monitoring fluid balance. Changes in body weight can indicate fluid retention or loss. Measuring and recording fluid intake and output (choice A) is important but may not reflect total body fluid status accurately. Assessing vital signs (choice C) and checking the client's lungs for crackles (choice D) are important assessments but do not directly provide the most accurate monitoring of fluid status.

5. The nurse has been assigned to train the unlicensed nursing assistant about prioritizing care. Which client should the nurse instruct the unlicensed nursing assistant to see first?

• A. The client who needs both sequential compression devices removed
• B. The elderly woman who needs assistance ambulating to the bathroom
• C. The surgical client who needs help changing the gown after bathing
• D. The male client who needs the intravenous fluid discontinued

Correct answer: A

Rationale: The correct answer is A. Removing sequential compression devices could increase the risk of thromboembolism, which is a serious complication. Therefore, this client should be seen first to prevent any potential harm. Choice B may be important, but it does not pose an immediate risk compared to thromboembolism. Choice C is a routine care task that can be delayed, and Choice D, discontinuing intravenous fluid, is important but not as urgent as preventing thromboembolism.

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