Nursing Elites

1. The nurse is caring for the client recovering from intestinal surgery. Which assessment finding would require immediate intervention?

• A. Presence of thin pink drainage in the Jackson Pratt
• B. Guarding when the nurse touches the abdomen
• C. Tenderness around the surgical site during palpation
• D. Complaints of chills and feeling feverish

Correct answer: D

Rationale: Complaints of chills and feeling feverish may indicate infection, which requires immediate intervention. This finding suggests a systemic response to infection, which can be life-threatening if not promptly addressed. Options A, B, and C are common postoperative findings and may not necessarily require immediate intervention unless accompanied by other concerning signs or symptoms.

2. The nurse counsels a client diagnosed with iron deficiency anemia. The nurse determines that teaching is effective if the client selects which of the following menus?

• A. Roast beef, brown rice, green beans, carrot and raisin salad, and milk
• B. Cheese pizza, tossed green salad, oatmeal-raisin cookie, and lemonade
• C. Two scrambled eggs, bacon, white toast with strawberry jam, and coffee
• D. Corn flakes with milk, whole wheat toast, and orange juice

Correct answer: A

Rationale: The correct answer is A. Roast beef is high in heme iron, which is best absorbed and helps treat iron deficiency anemia. Choices B, C, and D do not contain significant sources of iron, especially heme iron, making them less effective in treating iron deficiency anemia.

3. Why may patients with hiatal hernia develop anemia?

• A. Iron absorption is reduced
• B. Gastritis may cause bleeding
• C. Iron stores turn over more quickly
• D. Patients have an aversion to foods that are good sources of iron

Correct answer: B

Rationale: The correct answer is B: Gastritis may cause bleeding. In patients with hiatal hernia, gastritis can lead to gastrointestinal bleeding, resulting in anemia due to blood loss. Choice A is incorrect because hiatal hernia does not directly affect iron absorption. Choice C is incorrect as iron stores turning over more quickly is not a typical reason for anemia in hiatal hernia patients. Choice D is incorrect as an aversion to iron-rich foods does not directly cause anemia in this context.

4. Which of the following is NOT one of the three basic areas of concern into which practical nurse management responsibilities can be categorized?

• A. Managing patients' legal affairs
• B. Overseeing neurological functions
• C. Managing work center operations
• D. Managing personnel

Correct answer: A

Rationale: The correct answer is A: 'Managing patients' legal affairs.' Practical nurse management responsibilities are typically categorized into managing work center operations, managing personnel, and overseeing patient care. Legal affairs management is not a standard responsibility for practical nurse management. Choice B is incorrect as it introduces information about the hypothalamus, which is unrelated to the question. Choice C and D are both common areas of concern in practical nurse management, involving the operations of the work center and managing personnel, respectively.

5. The nurse is analyzing laboratory values for the assigned clients. Which finding, based on the client's medical history, indicates the need for immediate follow-up?

• A. Client with chronic kidney disease and serum creatinine of 1.6 mg/dL
• B. Client with diabetes mellitus and a glycosylated hemoglobin A (HbA1c) of 7.0%
• C. Client with heart failure and a B-type natriuretic peptide (BNP) of 140 pg/mL
• D. Client who is male and has anemia with hemoglobin of 16.5 g/dL and hematocrit of 45%

Correct answer: B

Rationale: An HbA1c of 7.0% in a client with diabetes mellitus indicates poor long-term glucose control, necessitating immediate follow-up. Elevated HbA1c levels suggest a higher average blood sugar over the past 2-3 months, increasing the risk of complications associated with diabetes. Choices A, C, and D do not require immediate follow-up based solely on the provided information. A serum creatinine of 1.6 mg/dL in a client with chronic kidney disease, a BNP of 140 pg/mL in a client with heart failure, and hemoglobin of 16.5 g/dL and hematocrit of 45% in a male client with anemia are within acceptable ranges or do not indicate an urgent need for intervention.

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