Nursing Elites

1. Which of the following describes the four-step method of assessment, planning, implementation, and evaluation?

• A. It is a problem-focused process of continued nursing care
• B. It is an open-ended process of continued nursing care
• C. It is a circular process of continued nursing care
• D. It is a trial-and-error process of continued nursing care

Correct answer: C

Rationale: The correct answer is C: 'It is a circular process of continued nursing care.' The four-step method of assessment, planning, implementation, and evaluation in nursing is a continuous and cyclical process. Choice A is incorrect because the method is not solely problem-focused; it involves a comprehensive approach. Choice B is incorrect as it does not capture the cyclical nature of the process. Choice D is incorrect as the method is systematic and not based on trial-and-error but rather evidence-based practice.

2. The nurse is caring for a client diagnosed with rule-out nephritic syndrome. Which intervention should be included in the plan of care?

• A. Monitor the urine for bright-red bleeding
• B. Evaluate the calorie count of the 500-mg protein diet
• C. Assess the client’s sacrum for dependent edema
• D. Monitor for a high serum albumin level

Correct answer: C

Rationale: Assessing the client’s sacrum for dependent edema is crucial in the care plan for nephritic syndrome as it is common due to protein loss. Dependent edema occurs as a result of decreased oncotic pressure from protein loss in the urine. Monitoring urine for bright-red bleeding (choice A) is more relevant to conditions like glomerulonephritis. Evaluating calorie count or protein intake (choice B) is important for other conditions but not specifically for nephritic syndrome. Monitoring for a high serum albumin level (choice D) is not typically part of the immediate care plan for nephritic syndrome.

3. The nurse is caring for a client in a sickle cell crisis. Which is the pain regimen of choice to relieve the pain?

• A. Frequent aspirin (acetylsalicylic acid) and a non-narcotic analgesic
• B. Motrin (ibuprofen), an NSAID, PRN
• C. Demerol (meperidine), a narcotic analgesic, every four (4) hours
• D. Morphine, a narcotic analgesic, every two (2) to three (3) hours PRN

Correct answer: D

Rationale: Morphine is the preferred analgesic in sickle cell crisis due to its potency and effectiveness in managing severe pain.

4. Enteral feedings may be appropriate for patients with:

• A. Acute cholecystitis
• B. Hepatic encephalopathy
• C. Ulcerative colitis in remission
• D. Acute exacerbation of Crohn’s disease

Correct answer: D

Rationale: Enteral feedings are commonly utilized for patients experiencing acute exacerbations of Crohn’s disease to provide necessary nutrition and rest the bowel. Choices A, B, and C are incorrect because enteral feedings are not typically indicated for acute cholecystitis, hepatic encephalopathy, or ulcerative colitis in remission.

5. The nurse is caring for clients on a cardiac floor. Which client should the nurse assess first?

• A. The client with three (3) unifocal PVCs in a minute
• B. The client diagnosed with coronary artery disease who wants to ambulate
• C. The client diagnosed with mitral valve prolapse with an audible S3
• D. The client diagnosed with pericarditis who is in normal sinus rhythm

Correct answer: C

Rationale: The correct answer is C because an audible S3 in a client with mitral valve prolapse could indicate heart failure, which requires immediate assessment. Choice A is less urgent as occasional unifocal PVCs are common. Choice B is important but can be addressed after the client with an audible S3. Choice D, a client with pericarditis in normal sinus rhythm, is stable compared to a client with potential heart failure symptoms.

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