Nursing Elites

1. When giving a report about a client who had a gastrectomy from the intensive care unit to the post-surgical unit nurse, what is the most effective way to assure essential information is reported?

• A. Give the report face-to-face with both nurses in a quiet room.
• B. Audiotape the report for future reference and documentation.
• C. Use a printed checklist with information individualized for the client.
• D. Document essential transfer information in the client's electronic health record.

Correct answer: C

Rationale: Using a printed checklist with individualized information is the most effective way to ensure that all key details about the client who had a gastrectomy are covered during the report. This method helps in structuring the information systematically, reducing the risk of missing important details. Face-to-face communication in a quiet room (Choice A) is important for effective communication but may not guarantee the coverage of all essential information. Audiotaping the report (Choice B) may not be practical for immediate reference or interaction. Documenting in the electronic health record (Choice D) is essential but may not facilitate a comprehensive real-time exchange of information between the nurses.

2. After a myocardial infarction, why is the hospitalized client taught to move the legs while resting in bed?

• A. Prepare the client for ambulation.
• B. Promote urinary and intestinal elimination.
• C. Prevent thrombophlebitis and blood clot formation.
• D. Decrease the likelihood of pressure ulcer formation.

Correct answer: C

Rationale: The correct answer is C. Moving the legs helps prevent thrombophlebitis and blood clot formation by promoting venous return in clients on bed rest. This prevents stasis and clot formation in the lower extremities. Choices A, B, and D are incorrect because the primary goal of moving the legs is to prevent thrombophlebitis and blood clot formation, rather than preparing for ambulation, promoting elimination, or decreasing pressure ulcer formation. Ambulation preparation involves different exercises, urinary and intestinal elimination are not directly related to leg movements, and pressure ulcer prevention is more related to repositioning and skin care.

3. An older client with long-term type 2 diabetes Mellitus (DM) is seen in the clinic for a routine health assessment. Which assessment would the nurse complete to determine if a patient with type 2 diabetes Mellitus (DM) is experiencing long-term complications?

• A. Signs of respiratory tract infection
• B. Sensation in feet and legs
• C. Skin condition of lower extremities
• D. Serum creatinine and blood urea nitrogen (BUN)

Correct answer: B

Rationale: Assessing sensation in the feet and legs is crucial for detecting diabetic neuropathy, a common long-term complication of diabetes. While signs of respiratory tract infection, skin condition of lower extremities, and serum creatinine and blood urea nitrogen levels are important assessments in diabetic care, they are not specific for detecting long-term complications like neuropathy.

4. A nurse reviews the urinalysis of a client and notes the presence of glucose. Which action should the nurse take?

• A. Document findings and continue to monitor the client.
• B. Contact the provider and recommend a 24-hour urine test.
• C. Review the client’s recent dietary selections.
• D. Perform a capillary artery glucose assessment.

Correct answer: D

Rationale: Glucose normally is not found in the urine. The normal renal threshold for glucose is about 220 mg/dL, which means that a person whose blood glucose is less than 220 mg/dL will not have glucose in the urine. A positive finding for glucose on urinalysis indicates high blood sugar. The most appropriate action would be to perform a capillary artery glucose assessment. The client needs further evaluation for this abnormal result; therefore, documenting and continuing to monitor is not appropriate. Requesting a 24-hour urine test or reviewing the client’s dietary selections will not assist the nurse to make a clinical decision related to this abnormality.

5. When assessing the lower extremities of a client with peripheral vascular disease (PVD), the nurse notes bilateral ankle edema. The edema is related to:

• A. Competent venous valves.
• B. Decreased blood volume.
• C. Increase in muscular activity.
• D. Increased venous pressure.

Correct answer: D

Rationale: The correct answer is 'Increased venous pressure.' In peripheral vascular disease (PVD), impaired blood flow leads to increased venous pressure in the lower extremities, causing fluid to leak out of the blood vessels and accumulate as edema. Choice A, 'Competent venous valves,' is incorrect because in PVD, the venous valves may be incompetent, contributing to venous pooling and edema. Choice B, 'Decreased blood volume,' is incorrect as PVD is associated with impaired blood flow rather than reduced blood volume. Choice C, 'Increase in muscular activity,' is incorrect as it does not directly relate to the development of edema in PVD.

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