Nursing Elites

1. After undergoing a pericardiocentesis, which interventions should the nurse implement?

• A. Monitor vital signs every 15 minutes for the first hour
• B. Evaluate the client’s cardiac rhythm
• C. Record the amount of fluid removed as output
• D. All of the above

Correct answer: D

Rationale: Following a pericardiocentesis, it is crucial for the nurse to monitor vital signs regularly, evaluate cardiac rhythm, and record the amount of fluid removed as output to detect any complications promptly. These interventions help in ensuring the client's safety and detecting any potential issues early. Therefore, selecting 'All of the above' (Choice D) is the correct answer as it encompasses all the essential interventions required post-pericardiocentesis. Choices A, B, and C are necessary actions to provide comprehensive care and monitor the client effectively.

2. Which of the following statements does NOT apply to a nursing plan of care?

• A. It contains short-term goals
• B. It is developed by the patient's physician
• C. It must be continually evaluated
• D. It contains long-range goals

Correct answer: B

Rationale: The correct answer is B. A nursing plan of care is developed by the nursing staff, not the patient's physician. Choice A is correct as nursing plans of care typically include short-term goals to address immediate needs. Choice C is also accurate as nursing plans of care need to be continually evaluated and updated to ensure they are effective. Choice D is incorrect as nursing plans of care can contain long-range goals to provide a roadmap for the patient's overall care and recovery.

3. 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.

4. The nurse is teaching the client diagnosed with colon cancer who is scheduled for a colostomy the next day. Which behavior indicates the best method of applying adult teaching principles?

• A. The nurse repeats the information as indicated by the client’s questions
• B. The nurse teaches all the information needed by the client in one session
• C. The nurse uses a video to explain with medical terms to the client
• D. The nurse waits until the client asks questions about the surgery

Correct answer: A

Rationale: Choice A is the best method of applying adult teaching principles because repeating information and addressing the client’s questions as they arise is effective for reinforcing learning in adults. This approach allows for clarification of doubts and ensures that the client understands the information provided. Choice B is incorrect as teaching all the information in one session may overwhelm the client and hinder retention. Choice C is incorrect as using medical terms without ensuring the client's understanding may lead to confusion. Choice D is incorrect because waiting for the client to ask questions may result in missed opportunities to address important information proactively.

5. The nurse on the postsurgical unit received a client that was transferred from the post-anesthesia care unit (PACU) and is planning care for this client. The nurse understands that staff should begin planning for this client’s discharge at which point during the hospitalization?

• A. Is admitted to the surgical unit
• B. Is transferred from the PACU to the postsurgical unit
• C. Is able to perform activities of daily living independently
• D. Has been assessed by the healthcare provider for the first time after surgery

Correct answer: A

Rationale: Discharge planning should begin as soon as the patient is admitted to the surgical unit to ensure a smooth transition. Option A is the correct choice because it marks the initial point in the hospitalization process where discharge planning should start. Options B, C, and D are not the ideal points to begin discharge planning. Option B only signifies a transfer within the hospital, while Option C relates to the patient's independence in activities of daily living, which is not directly linked to discharge planning. Option D, having the patient assessed by the healthcare provider for the first time after surgery, is unrelated to the timing of discharge planning.

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