Nursing Elites

1. The nurse is caring for a client recovering from intestinal surgery. Which assessment finding would require immediate intervention?

• A. Presence of thin pink drainage in the Jackson Pratt drain
• B. Guarding when the nurse touches the abdomen
• C. Tenderness around the surgical site during palpation
• D. Complaints of chills and feeling feverish

Correct answer: D

Rationale: Complaints of chills and feeling feverish may indicate infection, which requires immediate intervention. In this postoperative setting, the presence of thin pink drainage in the Jackson Pratt drain is expected as part of the normal healing process. Guarding when the nurse touches the abdomen and tenderness around the surgical site are common after surgery and may not require immediate intervention unless they are severe or accompanied by other concerning symptoms.

2. A client who _____ diet requires _____ amounts of vitamin C.

• A. Follows a vegan diet
• B. Smokes cigarettes
• C. Follows a ketogenic diet
• D. Is lactose intolerant

Correct answer: B

Rationale: Clients who smoke require more vitamin C due to increased oxidative stress and depletion of vitamin C. Smoking leads to higher levels of oxidative stress in the body, which in turn increases the utilization of vitamin C to counteract the damage caused by free radicals. Choices A, C, and D do not directly impact the body's need for vitamin C as smoking does.

3. The medical C4I headquarters has automated data processing systems that aid in which of the following?

• A. Patient accountability
• B. Tracking the movement of patients
• C. Management of health service logistics systems
• D. Patient accountability, tracking the movement of patients, and management of health service logistics systems

Correct answer: D

Rationale: The correct answer is D because the automated data processing systems in the medical C4I headquarters play a role in patient accountability, tracking the movement of patients, and managing health service logistics systems. These systems help in efficiently managing patient information, monitoring and coordinating patient movements, and optimizing the logistics involved in health services. Choices A, B, and C are incorrect because they represent individual aspects that are all encompassed by the functions of the automated data processing systems in the C4I headquarters.

4. Which laboratory data indicate the client’s pancreatitis is improving?

• A. The amylase and lipase serum levels are decreased
• B. The white blood cell count (WBC) is decreased
• C. The conjugated and unconjugated bilirubin levels are decreased
• D. The blood urea nitrogen (BUN) serum level is decreased

Correct answer: A

Rationale: The correct answer is A. Amylase and lipase are enzymes specifically related to pancreatitis. A decrease in their serum levels indicates improvement in pancreatitis. White blood cell count (WBC), choices C and D, are not direct markers for pancreatitis improvement. Bilirubin levels, choice C, are more related to liver function rather than pancreatitis. Blood urea nitrogen (BUN) level, choice D, is a marker for kidney function, not pancreatitis.

5. The nurse in the pediatric clinic performs a physical assessment of a 13-year-old boy. Which of the following findings by the nurse requires immediate intervention?

• A. The adolescent complains of his scrotum aching after exercise. The nurse palpates a worm-like mass above the testes.
• B. The nurse noted unilateral breast enlargement.
• C. The child’s scrotum appears swollen, and a soft mass is palpated. The nurse is unable to insert a finger above the mass.
• D. The child’s scrotum appears enlarged and red. The nurse palpated a thickened and swollen spermatic cord.

Correct answer: D

Rationale: Choice D is the correct answer because a swollen and thickened spermatic cord could indicate testicular torsion, which is a surgical emergency. Testicular torsion occurs when the spermatic cord twists, cutting off the blood supply to the testicle. This condition requires immediate intervention to prevent testicular damage. Choices A, B, and C do not present findings that suggest a surgical emergency requiring immediate intervention.

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