Nursing Elites

1. The client is four hours post-operative abdominal aortic aneurysm repair. Which nursing intervention should be implemented for this client?

• A. Assist the client in ambulating
• B. Assess the client's bilateral pedal pulses
• C. Maintain a continuous IV heparin drip
• D. Provide clear liquids to the client

Correct answer: B

Rationale: Assessing the client's bilateral pedal pulses is essential in this situation as it helps in evaluating the peripheral perfusion and circulation in the lower extremities. This assessment is crucial to detect any signs of decreased blood flow or complications, such as arterial occlusion or thrombosis. Ambulating the client may be important in the postoperative period, but assessing pedal pulses takes priority to ensure adequate perfusion. Maintaining continuous IV heparin drip is not typically indicated immediately post-operatively for an abdominal aortic aneurysm repair, as the risk of bleeding complications may outweigh the benefits. Providing a clear liquid diet is not a priority nursing intervention at this stage, as the focus should be on vascular assessment and postoperative monitoring.

2. Which of the following is inappropriate in collecting midstream clean-catch urine specimen for urine analysis?

• A. Collect early in the morning, first voided specimen
• B. Do perineal care before specimen collection
• C. Collect 5 to 10 ml of urine
• D. Discard the first flow of urine

Correct answer: C

Rationale: The inappropriate action in collecting a midstream clean-catch urine specimen for urine analysis is to collect only 5 to 10 ml of urine. Adequate urine volume of 30 to 60 ml is required for accurate testing. Collecting a small amount like 5 to 10 ml may lead to inaccurate results due to insufficient sample size. It is crucial to follow proper collection techniques, such as discarding the first flow of urine, performing perineal care, and collecting an adequate volume, to ensure reliable test results.

3. A patient taking anticoagulants should be cautious about consuming which type of food?

• A. High-protein foods
• B. High-fiber foods
• C. High-vitamin K foods
• D. High-calcium foods

Correct answer: C

Rationale: The correct answer is C: High-vitamin K foods. Foods high in vitamin K can interfere with the effectiveness of anticoagulants. Vitamin K plays a crucial role in blood clotting, so consuming high amounts of it can counteract the anticoagulant effects. Choices A, B, and D are incorrect as they do not directly interfere with the action of anticoagulants.

4. Infection or inflammation of small sacs that protrude from the lumen of the colon is known as:

• A. Diverticulosis
• B. Diverticulitis
• C. Cholelithiasis
• D. Cholecystitis

Correct answer: B

Rationale: Diverticulitis refers to the infection or inflammation of diverticula in the colon. Choice A, Diverticulosis, is the condition of having diverticula without inflammation. Choices C and D, Cholelithiasis and Cholecystitis, are related to the gallbladder and not the colon, making them incorrect in this context.

5. After undergoing a pericardiocentesis, which interventions should the nurse implement?

• A. Monitor vital signs every 15 minutes for the first hour
• B. Evaluate the client’s cardiac rhythm
• C. Record the amount of fluid removed as output
• D. All of the above

Correct answer: D

Rationale: Following a pericardiocentesis, it is crucial for the nurse to monitor vital signs regularly, evaluate cardiac rhythm, and record the amount of fluid removed as output to detect any complications promptly. These interventions help in ensuring the client's safety and detecting any potential issues early. Therefore, selecting 'All of the above' (Choice D) is the correct answer as it encompasses all the essential interventions required post-pericardiocentesis. Choices A, B, and C are necessary actions to provide comprehensive care and monitor the client effectively.

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