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 crucial at this point to monitor the perfusion to the lower extremities after abdominal aortic aneurysm repair surgery. Ambulation (Choice A) may be appropriate but should be guided by the assessment findings. Maintaining a continuous IV heparin drip (Choice C) is not typically indicated post-operatively for this type of surgery. Providing clear liquids (Choice D) may not be suitable immediately after the surgery, as the client needs time to recover before resuming oral intake.

2. What is the FIRST step in providing health care for a patient?

• A. Obtain and interpret vital signs
• B. Determine the needs of the patient
• C. Develop a plan of care
• D. Obtain lab work and x-rays

Correct answer: B

Rationale: The correct first step in providing health care for a patient is to determine the needs of the patient. Understanding the patient's requirements, concerns, and medical history is crucial before proceeding with any further steps. Option A, 'Obtain and interpret vital signs,' may be necessary but typically follows assessing the patient's needs. Option C, 'Develop a plan of care,' comes after identifying the patient's needs. Option D, 'Obtain lab work and x-rays,' is usually done based on the patient's needs and the developed plan of care, making it a later step in the process.

3. In determining and fulfilling the nursing care needs of the patient, which step involves assessing whether the care provided is appropriate and effective in relation to the patient's current physiological and psychological status?

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

Correct answer: A

Rationale: The correct answer is A, 'Evaluation.' Evaluation in nursing involves assessing whether the care provided is appropriate and effective in relation to the patient's current physiological and psychological status. This step helps determine the outcomes of the care provided and if any changes are needed. Choice B, 'Planning,' focuses on developing a plan of care based on the assessment findings. Choice C, 'Implementation,' involves carrying out the plan of care. Choice D, 'Assessment,' is the initial step in the nursing process that involves gathering data about the patient's health status.

4. During a physical assessment of a newborn, which of the following findings should the nurse prioritize reporting?

• A. Head circumference of 40 cm
• B. Chest circumference of 32 cm
• C. Acrocyanosis and edema of the scalp
• D. Heart rate of 160 bpm and respirations of 40/min

Correct answer: A

Rationale: The correct answer is A. A head circumference of 40 cm is abnormally large for a newborn and could indicate conditions like hydrocephalus or other abnormalities, making it a crucial finding to report. Choices B, C, and D are within normal parameters for a newborn and do not pose immediate concerns. Chest circumference of 32 cm is a normal finding. Acrocyanosis and edema of the scalp are common in newborns due to physiological adaptations. A heart rate of 160 bpm and respirations of 40/min may be within the normal range for a newborn.

5. 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.

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