Nursing Elites

1. Performing and supervising therapeutic and preventive procedures that have been planned for a patient 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: C

Rationale: The correct answer is C: Implementation. In nursing care, implementation involves carrying out and supervising the planned procedures for the patient. This step focuses on putting the care plan into action. Choice A, Evaluation, involves assessing the effectiveness of the care provided, not performing procedures. Choice B, Planning, is about developing a plan of care, not executing it. Choice D, Assessment, is the initial step in the nursing process where data is collected and analyzed to determine the patient's needs, not the step involving performing and supervising procedures.

2. 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.

3. What nutrient can be obtained from broccoli and is related to the concept of increased excretion?

• A. Potassium
• B. Increased excretion
• C. Broccoli
• D.

Correct answer: C

Rationale: The correct answer is C, Broccoli. Broccoli is a good source of potassium. Increased excretion can be related to the dietary intake of nutrients like potassium. Choice A, Potassium, is a nutrient obtained from broccoli but is not directly related to increased excretion. Choice B, Increased excretion, is a process rather than a nutrient obtained from broccoli, making it an incorrect choice.

4. The nurse teaches the mother of an infant how to care for her infant following repair of a cleft lip. It is MOST important for the nurse to include which of the following instructions?

• A. Feed the infant with a newborn nipple while holding him in the recumbent position
• B. Clean the suture site with a cotton-tipped swab soaked in Betadine
• C. Place the infant in the prone position after feeding
• D. Feed the infant with a rubber-tipped syringe and burp frequently

Correct answer: D

Rationale: The correct answer is D because feeding the infant with a rubber-tipped syringe reduces the risk of injury to the surgical site and prevents aspiration. Choice A is incorrect because feeding an infant with a cleft lip using a newborn nipple while in the recumbent position can increase the risk of aspiration. Choice B is incorrect as Betadine is not typically used on suture sites due to its cytotoxic effects. Choice C is incorrect because placing the infant in the prone position after feeding can also increase the risk of aspiration.

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 an 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: A swollen and thickened spermatic cord could indicate testicular torsion, which is a surgical emergency.

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