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 describes the four-step method of assessment, planning, implementation, and evaluation?

• A. It is a problem-focused process of continued nursing care
• B. It is an open-ended process of continued nursing care
• C. It is a circular process of continued nursing care
• D. It is a trial-and-error process of continued nursing care

Correct answer: C

Rationale: The correct answer is C: 'It is a circular process of continued nursing care.' The four-step method of assessment, planning, implementation, and evaluation in nursing is a continuous and cyclical process. Choice A is incorrect because the method is not solely problem-focused; it involves a comprehensive approach. Choice B is incorrect as it does not capture the cyclical nature of the process. Choice D is incorrect as the method is systematic and not based on trial-and-error but rather evidence-based practice.

3. Participating in the development of long-term and preventive health goals with the patient and their family is part of which of the following steps for determining and fulfilling the nursing care needs of the patient?

• A. Evaluation
• B. Planning
• C. Implementation
• D. Assessment

Correct answer: B

Rationale: The correct answer is B: Planning. Planning in nursing care involves setting long-term and preventive goals for the patient in collaboration with the patient and their family. This step ensures that a comprehensive and individualized care plan is developed. Choice A, Evaluation, comes after the interventions have been implemented to assess their effectiveness. Choice C, Implementation, is the step where the care plan is put into action. Choice D, Assessment, is the initial step that involves collecting data to identify the patient's needs, which is done before planning the care.

4. Which endocrine disorder would the nurse assess for in a client who has a closed head injury with increased intracranial pressure?

• A. Pheochromocytoma
• B. Diabetes insipidus
• C. Hashimoto’s disease
• D. Gynecomastia

Correct answer: B

Rationale: The correct answer is B, Diabetes insipidus. Diabetes insipidus can develop after a head injury due to damage to the hypothalamus or pituitary gland, leading to a deficiency in antidiuretic hormone (ADH). Pheochromocytoma (choice A) is a tumor of the adrenal gland and is not directly related to closed head injury or increased intracranial pressure. Hashimoto’s disease (choice C) is an autoimmune disorder affecting the thyroid gland, not commonly associated with head injuries. Gynecomastia (choice D) is the development of breast tissue in males and is not an endocrine disorder typically linked to closed head injuries.

5. In assessing the client's chest, which position best shows chest expansion as well as its movements?

• A. Sitting
• B. Prone
• C. Sidelying
• D. Supine

Correct answer: A

Rationale: The correct answer is A: Sitting. When the client is seated, their chest is in an optimal position for observing the full range of chest expansion during breathing. This position allows for easy visualization of chest movements and expansion as the client breathes in and out, providing a comprehensive assessment of respiratory function. Choice B, Prone, is incorrect as lying face down would not provide a clear view of chest expansion. Choice C, Sidelying, is also incorrect as this position may limit the visibility of chest movements. Choice D, Supine, is not the best position for assessing chest expansion as it may not offer a clear observation of chest movements during breathing.

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