Nursing Elites

1. What intervention would be the most important for the nurse to implement for the client with a left nephrectomy?

• A. Assess the intravenous fluids for rate and volume
• B. Change the surgical dressing every day at the same time
• C. Monitor the client’s medication levels daily
• D. Monitor the percentage of each meal eaten

Correct answer: A

Rationale: The most important intervention for a client with a left nephrectomy is to assess the intravenous fluids for rate and volume. After nephrectomy, monitoring intravenous fluids is crucial to ensure proper hydration and kidney function. Changing the surgical dressing daily, monitoring medication levels, and tracking meal intake are also important aspects of care but not as critical as ensuring adequate intravenous fluid management post-surgery.

2. What are three major causes of atherosclerosis?

• A. Hyperthyroidism, underweight, and poor appetite
• B. High blood cholesterol, high blood pressure, and cigarette smoking
• C. Constipation, peptic ulcer disease, and pancreatitis
• D. Kidney failure, edema, and sodium retention

Correct answer: B

Rationale: The correct answer is B: High blood cholesterol, high blood pressure, and cigarette smoking are three major causes of atherosclerosis. Atherosclerosis is mainly attributed to the buildup of cholesterol-rich plaques in the arteries, high blood pressure causing damage to the arterial walls, and the harmful effects of cigarette smoking on blood vessels. Choices A, C, and D are incorrect because they do not directly relate to the primary causes of atherosclerosis.

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. Neomycin may decrease absorption of which nutrient?

• A. Iron, copper, and zinc
• B. Protein and amino acids
• C. Fat-soluble vitamins
• D. Water-soluble vitamins

Correct answer: C

Rationale: The correct answer is C: Fat-soluble vitamins. Neomycin is known to interfere with the absorption of fat-soluble vitamins. This is because neomycin can disrupt the normal gut flora responsible for the absorption of these vitamins. Choices A, B, and D are incorrect because neomycin primarily affects the absorption of fat-soluble vitamins, not minerals, proteins, amino acids, or water-soluble vitamins.

5. The client diagnosed with thalassemia, a hereditary anemia, is to receive a transfusion of packed RBCs. The cross-match reveals the presence of antibodies that cannot be cross-matched. Which precaution should the nurse implement when initiating the transfusion?

• A. Start the transfusion at 10-15 mL per hour for 15-30 minutes
• B. Re-crossmatch the blood until the antibodies are identified
• C. Have the client sign a permit to receive uncrossmatched blood
• D. Have the unlicensed nursing assistant stay with the client

Correct answer: A

Rationale: Starting the transfusion slowly at 10-15 mL per hour for 15-30 minutes is the correct precaution to implement when the cross-match reveals the presence of antibodies that cannot be cross-matched. This allows the nurse to monitor for any adverse reactions due to the presence of antibodies. Re-crossmatching the blood until the antibodies are identified is not practical and may delay the transfusion, potentially compromising the patient's condition. Having the client sign a permit to receive uncrossmatched blood is not the best course of action as the focus should be on ensuring a safe transfusion. Having an unlicensed nursing assistant stay with the client does not address the specific precaution needed to manage a transfusion in the presence of antibodies.

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