Nursing Elites

1. The nurse is preparing a postoperative nursing care plan for the client recovering from a hemorrhoidectomy. Which intervention should the nurse implement?

• A. Establish a rapport with the client to decrease embarrassment during site assessment
• B. Encourage the client to lie in the lithotomy position twice a day
• C. Milk the tube inserted during surgery to facilitate the passage of flatus
• D. Digitally dilate the rectal sphincter to express old blood

Correct answer: A

Rationale: Establishing rapport with the client is crucial in postoperative care to create a trusting relationship, reduce embarrassment, and enhance comfort during assessments. Encouraging the client to lie in the lithotomy position is not recommended after a hemorrhoidectomy as it can be uncomfortable and may disrupt wound healing. Milking the tube inserted during surgery is not a standard practice and could lead to complications. Digitally dilating the rectal sphincter is not indicated post-hemorrhoidectomy and can cause harm to the client.

2. The nurse writes a problem of “potential for complication related to ovarian hyperstimulation” for a client who is taking clomiphene (Clomid), an ovarian stimulant. Which intervention should be included in the plan of care?

• A. Instruct the client to delay intercourse until menses
• B. Schedule the client for frequent pelvic sonograms
• C. Explain that the infusion therapy will take 21 days
• D. Discuss that this may cause an ectopic pregnancy

Correct answer: B

Rationale: Frequent pelvic sonograms help monitor for ovarian hyperstimulation, a serious potential side effect of clomiphene. Instructing the client to delay intercourse until menses (Choice A) is not directly related to monitoring for ovarian hyperstimulation. Explaining the duration of infusion therapy (Choice C) is not relevant to monitoring for this specific complication. Discussing the risk of ectopic pregnancy (Choice D) is important, but it is not the most appropriate intervention for monitoring ovarian hyperstimulation.

3. 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 is a continuous and cyclical process in nursing care. Choice A is incorrect because the method is not solely problem-focused but involves multiple steps. Choice B is incorrect as it does not capture the structured nature of the four-step method. Choice D is incorrect as it implies a random approach rather than a systematic and organized process.

4. During the admission interview, which question should the nurse ask the male client diagnosed with aorto-iliac disease?

• A. “Do you have trouble sitting for long periods of time?”
• B. “How often do you have a bowel movement and urinate?”
• C. “When you lie down do you feel throbbing in your abdomen?”
• D. “Have you experienced any problems having sexual intercourse?”

Correct answer: D

Rationale: The correct question for the nurse to ask the male client diagnosed with aorto-iliac disease during the admission interview is about any problems experienced during sexual intercourse. Aorto-iliac disease can lead to impaired blood flow to the pelvis and lower extremities, affecting sexual function. Therefore, it is essential to assess the client's sexual health in such cases. The other options, such as sitting for long periods of time, bowel movements and urination frequency, and throbbing sensation when lying down, are not directly related to the potential impact of aorto-iliac disease on sexual function. Hence, they are not the most pertinent questions to ask during the admission interview.

5. Listed below are five categories that identify the responsibilities of the practical nurse manager in personnel management. Which of these categories is most appropriate for the task of training soldiers for survival on the battlefield?

• A. Accountability
• B. Personal/professional development
• C. Individual training
• D. Military appearance/physical condition

Correct answer: C

Rationale: The correct answer is C: Individual training. Individual training involves preparing soldiers for specific tasks like survival on the battlefield. Accountability (choice A) refers to being answerable for one's actions, not directly related to training soldiers. Personal/professional development (choice B) focuses on growth and advancement of individuals, not specific training for battlefield survival. Military appearance/physical condition (choice D) pertains to the physical attributes and presentation of soldiers, not directly related to training them for survival.

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