Nursing Elites

1. The functional health pattern assessment data states: 'Eats three meals a day and is of normal weight for height.' The nurse should draw which of the following conclusions about this data? Select all that apply.

• A. Client has an actual health problem
• B. Client has a wellness diagnosis
• C. Collaborative health problem needs to be written
• D. Possible nursing diagnosis exists

Correct answer: B

Rationale: The assessment data provided indicates a healthy pattern of nutrition and a normal weight for height, suggesting a positive health status. This aligns with a wellness diagnosis, such as 'Potential for enhanced nutrition,' which focuses on improving health further. An actual health problem refers to a current health issue present in the client, which is not evident in this data. Collaborative health problems involve interprofessional collaboration and are not indicated based on the information provided. While a diet assessment may be needed to evaluate food quality, the initial data suggests a wellness-focused approach to care.

2. The Sinoatrial Node (SA) is located within which of the following heart structures?

• A. Mitral Valve
• B. Right Ventricle
• C. Right Atrium
• D. Left Atrium

Correct answer: C

Rationale: The Sinoatrial (SA) Node, often called the heart's natural pacemaker, is situated within the upper wall of the Right Atrium. It initiates the electrical impulses that regulate the heartbeat. Choices A, B, and D are incorrect because the SA node is not located in the Mitral Valve, Right Ventricle, or Left Atrium. It is specifically positioned in the Right Atrium to coordinate the heart's rhythm and timing.

3. Which statement best describes evidence-based practice?

• A. Reading and analyzing research reports to determine their implementation in nursing practice
• B. Collecting data to evaluate the efficiency of nursing practice in delivering quality care
• C. Monitoring unit practices to ensure adherence to Joint Commission standards
• D. Using the most effective, current, and applicable information to guide nursing care for the best outcomes

Correct answer: D

Rationale: Evidence-based practice involves utilizing the most effective, current, and relevant information to inform nursing care decisions for optimal client outcomes. While research reports and data collection are important components of evidence-based practice, the essence lies in integrating all available information to determine the best course of action. Monitoring compliance with standards, as described in choices A and C, is essential for quality assurance but does not capture the comprehensive nature of evidence-based practice.

4. During an examination of a patient's abdomen, the nurse notes that the abdomen is rounded and firm to the touch. During percussion, the nurse notes a drum-like quality of the sounds across the quadrants. How would the nurse interpret this type of sound?

• A. Constipation
• B. Air-filled areas
• C. Presence of a tumor
• D. Presence of dense organs

Correct answer: B

Rationale: A musical or drum-like sound (tympany) is heard when percussion occurs over an air-filled viscus, such as the stomach or intestines. This indicates the presence of air-filled areas. Constipation, choice A, does not produce specific percussion sounds and is related to bowel movements rather than the sound produced during percussion. The presence of a tumor, choice C, would not typically produce a drum-like sound but might result in dullness or decreased resonance. Dense organs, choice D, would produce a dull thud sound rather than a drum-like tympanic sound.

5. A 51-year-old woman had an incisional cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient to

• A. choose low-fat foods from the menu
• B. perform leg exercises hourly while awake
• C. ambulate the evening of the operative day
• D. turn, cough, and deep breathe every 2 hours

Correct answer: D

Rationale: Postoperative nursing care after a cholecystectomy focuses on preventing respiratory complications due to the surgical incision being high in the abdomen, which impairs coughing and deep breathing. Turning, coughing, and deep breathing every 2 hours help prevent respiratory complications, such as pneumonia. While choices A, B, and C are also important aspects of postoperative care, they are not as high a priority as ensuring proper ventilation and respiratory function in the immediate postoperative period.

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