Nursing Elites

1. Protecting the rights and privacy of the patient and their family is part of which of the following steps for determining and fulfilling the nursing care needs of the patient?

• A. Evaluation
• B. Planning
• C. Implementation
• D. Assessment

Correct answer: C

Rationale: The correct answer is C: Implementation. Implementation is the phase where the nursing care plan is put into action, which includes safeguarding the patient's and their family's rights and privacy. Evaluation (choice A) involves reviewing the effectiveness of the care plan, Planning (choice B) is the phase where the care plan is developed, and Assessment (choice D) is the initial step where data about the patient is collected.

2. 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 that necessitate immediate intervention. Choice A is incorrect as constipation in a client with an abdominal aortic aneurysm, while important, does not indicate an immediate crisis. Choice B is incorrect as a client on bed rest ambulating to the bathroom is a positive sign. Choice D is incorrect because a decreased pedal pulse in arterial occlusive disease should be addressed promptly, but it does not indicate an acute emergency like a hypertensive crisis.

3. The client is recovering from a percutaneous renal biopsy. Which data indicate that the client is complying with client teaching?

• A. The client lies flat in the supine position for 12 hours
• B. The client continues oral fluids restriction while on bed rest
• C. The client’s family changed the dressing on return to the room
• D. The family activates the patient-controlled analgesia pump

Correct answer: A

Rationale: The correct answer is A. Lying flat in the supine position for 12 hours after a renal biopsy helps prevent bleeding, which is crucial for the client's recovery. This position aids in applying pressure to the biopsy site, reducing the risk of bleeding and ensuring optimal healing. Choices B, C, and D do not directly relate to compliance with client teaching after a renal biopsy. Continuing oral fluids restriction, changing the dressing, or activating a patient-controlled analgesia pump are not specific instructions aimed at promoting recovery and preventing complications post renal biopsy.

4. The nurse is administering a beta blocker to the client diagnosed with essential hypertension. Which data would cause the nurse to question administering the medication?

• A. The client’s BP is 110/70
• B. The client’s potassium level is 3.4 mEq/L
• C. The client has a barky cough
• D. The client’s apical pulse is 56

Correct answer: D

Rationale: The correct answer is D. A beta blocker should be withheld if the apical pulse is below 60, as it can further decrease the heart rate. Choice A is not a reason to question administering the medication as the blood pressure is within a normal range for a client with essential hypertension. Choice B is not directly related to the administration of a beta blocker. Choice C suggests a potential side effect of an ACE inhibitor, not a beta blocker.

5. Which question should the healthcare provider ask when assessing the client for an endocrine dysfunction?

• A. “Have you noticed any pain in your legs when walking?”
• B. “Have you had any unexplained weight loss?”
• C. “Have you noticed any change in your bowel movements?”
• D. “Have you experienced any joint pain or discomfort?”

Correct answer: B

Rationale: The correct answer is B: “Have you had any unexplained weight loss?” Unexplained weight loss can be a significant symptom of various endocrine disorders, such as hyperthyroidism and diabetes. Weight changes are often closely linked to endocrine dysfunction due to the hormonal imbalances affecting metabolism. Choices A, C, and D are less specific to endocrine dysfunction. Pain in the legs, changes in bowel movements, and joint pain or discomfort are symptoms that can be related to various health conditions but are not as indicative of endocrine disorders as unexplained weight loss.

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