Nursing Elites

1. Which of these types of fluid output is not typically measured?

• A. chest tube drainage
• B. emesis
• C. evaporative water from the respiratory tract
• D. urine

Correct answer: D

Rationale: The correct answer is 'urine.' Urine output is routinely measured to assess renal function and fluid balance. Choices A, B, and C are types of fluid output that are typically measured in a clinical setting. Chest tube drainage is monitored to evaluate drainage from the chest cavity, emesis refers to vomitus which can indicate gastrointestinal issues, and evaporative water from the respiratory tract is considered insensible loss and is not directly measured but estimated in overall fluid balance assessments.

2. During surgery, it is found that a client with adenocarcinoma of the rectum has positive peritoneal lymph nodes. What is the next most likely site of metastasis?

• A. brain
• B. bone
• C. liver
• D. mediastinum

Correct answer: C

Rationale: In cases of adenocarcinoma of the rectum with positive peritoneal lymph nodes, the most likely site of metastasis is the liver. Colon tumors commonly spread through the lymphatics and portal vein to the liver. While metastasis to the brain, bone, or mediastinum is possible, the liver is typically the first to be affected due to the anatomical pathways involved in colorectal cancer metastasis. Therefore, the correct answer is the liver. Metastasis to the brain, bone, or mediastinum would be less likely at this stage of colorectal cancer progression.

3. Which of these statements from the caregiver of a palliative care client indicates a proper understanding?

• A. This treatment plan usually indicates a prognosis of less than 6 months.
• B. We will need to stay in the hospital to receive this level of care.
• C. The main therapeutic goals are comfort and better quality of life.
• D. The medications to treat the underlying disease will be continued.

Correct answer: C

Rationale: The correct answer is 'The main therapeutic goals are comfort and better quality of life.' This statement reflects a proper understanding of palliative care, which focuses on improving the patient's quality of life and providing comfort. It does not necessarily mean a prognosis of less than 6 months or require hospitalization. Choice A is incorrect because palliative care can be provided regardless of the prognosis. Choice B is wrong as palliative care can be administered in various settings, not just hospitals. Choice D is inaccurate as palliative care aims to improve symptoms and quality of life, so medications may be adjusted but not necessarily stopped.

4. What type of injury is associated with acute hyphema?

• A. orthopedic
• B. eye
• C. insect sting or snakebite
• D. gynecological trauma

Correct answer: B

Rationale: Acute hyphema is associated with an eye injury, typically resulting from blunt trauma. The presence of blood in the anterior chamber of the eye causes a half-moon appearance or a horizontal line across the globe when the client is upright. Choices A, C, and D are incorrect because acute hyphema is not related to orthopedic injuries, insect stings, snakebites, or gynecological trauma.

5. Nurse Ann tells nurse Christine that one of her client's status is declining but that she will do her best to juggle her other two clients. Which action is most appropriate?

• A. Nurse Christine should offer to give medications to Nurse Ann's other two clients.
• B. Nurse Christine should inform their supervisor that assignments may need to be changed.
• C. Nurse Christine should ask other nurses who might be able to help Nurse Ann.
• D. Nurse Ann should try not to burden other nurses and continue caring for her assigned clients.

Correct answer: B

Rationale: In this situation, when Nurse Ann informs Nurse Christine that a client's status is declining and she needs to attend to them, the most appropriate action for Nurse Christine is to inform their supervisor that assignments may need to be changed. By informing the supervisor, necessary adjustments can be made to ensure proper care for all clients. Offering to give medications to Nurse Ann's other two clients (choice A) may not address the underlying issue of a declining client and could lead to a delay in care. Asking other nurses for help (choice C) might not be the most efficient solution, as the supervisor is responsible for reassigning tasks. Nurse Ann continuing to care for all her assigned clients (choice D) may compromise the quality of care provided to the declining client and may spread her too thin, impacting all clients negatively.

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