Nursing Elites

1. The client is admitted to the emergency department complaining of acute epigastric pain and reports vomiting a large amount of bright red blood at home. Which interventions should the nurse implement?

• A. Assess the client’s vital signs
• B. Start an IV with an 18-gauge needle
• C. Begin iced saline lavage
• D. A, B

Correct answer: D

Rationale: In this scenario, the client's presentation of acute epigastric pain and vomiting bright red blood indicates a potential gastrointestinal bleeding emergency. Assessing the client's vital signs is essential to monitor their hemodynamic status. Starting an IV with an 18-gauge needle is crucial to establish access for potential fluid resuscitation or blood transfusion. Beginning iced saline lavage is not appropriate in this situation and could potentially delay necessary interventions. Therefore, the correct interventions for the nurse to implement are to assess the client’s vital signs and start an IV, making option D the most appropriate choice. Options A and B are correct because they are essential initial steps in managing gastrointestinal bleeding. Option C is incorrect as iced saline lavage is not indicated and may not address the urgent needs of the client in this critical situation.

2. The nurse is caring for the client one (1) day postoperative sigmoid colostomy operation. Which independent nursing intervention should the nurse implement?

• A. Change the infusion rate of the intravenous fluid
• B. Encourage the client to discuss his or her feelings
• C. Administer opioid narcotic medications for pain management
• D. Assist the client out of bed to sit in the chair twice daily

Correct answer: D

Rationale: Assisting the client to sit in a chair is a crucial nursing intervention postoperatively. It helps prevent complications such as thrombosis, pneumonia, and pressure ulcers by promoting circulation and aiding in recovery. Changing the infusion rate of the intravenous fluid would require a physician's order and is not within the nurse's independent scope of practice. Encouraging the client to discuss feelings and administering medications for pain management are important interventions but may not be as immediately necessary as assisting the client in mobilizing early postoperatively.

3. Determining nursing care priorities is a part of which of the following steps in determining and fulfilling the nursing care needs of the patient?

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

Correct answer: B

Rationale: Corrected Rationale: Planning in nursing involves setting priorities based on the patient's needs, resources, and desired outcomes. It includes organizing and coordinating care activities to achieve the identified goals. Therefore, determining nursing care priorities is a key aspect of the planning phase.\n Incorrect Rationales:\n- Evaluation (Choice A) comes after implementing the care plan to assess the effectiveness of interventions and make necessary adjustments.\n- Implementation (Choice C) is the phase where the care plan is put into action, involving carrying out the nursing interventions designed during the planning phase.\n- Assessment (Choice D) is the initial step in the nursing process where data about the patient's health status is collected and analyzed to identify needs and formulate a care plan. It precedes planning and determining care priorities.

4. Which of the following is NOT a terminal learning objective for Phase I of the M6 Practical Nurse Course?

• A. Identify principles of basic-level anatomy, physiology, microbiology, and nutrition
• B. Perform basic-level pharmacological calculations
• C. Integrate the knowledge of drug therapy into nursing practice
• D. Identify basic principles of field nursing

Correct answer: C

Rationale: The correct answer is C. Integrating drug therapy knowledge is not a terminal learning objective for Phase I of the M6 Practical Nurse Course. Choices A, B, and D are all relevant terminal learning objectives for Phase I, focusing on understanding basic-level anatomy, physiology, microbiology, nutrition, performing pharmacological calculations, and identifying basic principles of field nursing, respectively.

5. The nurse had developed a close relationship with the family of a client who is dying. Which nursing intervention(s) are most appropriate in dealing with the family?

• A. Encouraging family discussion of feelings
• B. Accepting the family’s experience of anger
• C. Facilitating the use of spiritual practices identified by the family
• D. All of the above

Correct answer: D

Rationale: When a nurse has established a close relationship with a dying client's family, it is important to offer holistic support. Encouraging family discussion of feelings allows them to express and process their emotions, accepting the family's experience of anger validates their feelings, and facilitating the use of spiritual practices identified by the family can provide comfort and solace. Therefore, all of the above interventions are crucial in dealing with the family during such a challenging time. Choices A, B, and C work together to provide comprehensive emotional and spiritual support, making option D the correct answer.

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