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 client has failed to conceive after many attempts over a three-year time period and asks the nurse, “I have tried everything. What should I do now?” Which statement is the nurse’s best response?

• A. Assess the intravenous fluids for rate and volume
• B. Change the surgical dressing every day at the same time
• C. Monitor the client’s medication levels daily
• D. Monitor the percentage of each meal eaten

Correct answer: A

Rationale: The correct response is to assess the intravenous fluids for rate and volume. In this situation, the client is seeking guidance on fertility issues, not related to intravenous fluids, surgical dressing changes, medication levels, or meal monitoring. The nurse should provide supportive and empathetic guidance, suggesting further options like consulting fertility specialists or exploring additional treatments.

3. The nurse is caring for clients on a medical floor. Which client will the nurse assess first?

• A. The client with an abdominal aortic aneurysm who is constipated
• B. The client on bed rest who ambulated to the bathroom
• C. The client with essential hypertension who has epistaxis and a headache
• D. The client with arterial occlusive disease who has a decreased pedal pulse

Correct answer: C

Rationale: The correct answer is C because epistaxis and headache in a client with hypertension are signs of a hypertensive crisis, requiring immediate intervention. Option A is incorrect as constipation in a client with an abdominal aortic aneurysm, though important, does not indicate an immediate need for assessment. Option B, a client on bed rest who ambulated to the bathroom, does not present with urgent signs or symptoms requiring immediate assessment. Option D, a client with arterial occlusive disease and a decreased pedal pulse, needs attention but is not the priority compared to a hypertensive crisis with epistaxis and headache.

4. A client who is postpartum and diagnosed with iron deficiency anemia is receiving education from a nurse. Which dietary recommendation should be included in the education plan?

• A. Yogurt and mozzarella
• B. Spinach and beef
• C. Fish and cottage cheese
• D. Turkey slices and milk

Correct answer: B

Rationale: The correct answer is B: Spinach and beef. Spinach is a good source of non-heme iron, while beef provides heme iron, both essential for treating iron deficiency anemia. Yogurt and mozzarella (choice A) are not significant sources of iron. Fish and cottage cheese (choice C) do not provide as much iron as spinach and beef. Turkey slices and milk (choice D) are also not as rich in iron compared to spinach and beef.

5. What is the initial step in providing healthcare 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 initial step in providing healthcare for a patient is to determine the needs of the patient. This step involves assessing the patient's condition, listening to their concerns, and understanding what care or treatment they require. Obtaining and interpreting vital signs (Choice A) is a crucial step but typically follows the assessment of the patient's needs. Developing a plan of care (Choice C) and obtaining lab work and x-rays (Choice D) come after understanding the patient's needs and assessing their condition.

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