Nursing Elites

1. The client is diagnosed with pericarditis. When assessing the client, the nurse is unable to auscultate a friction rub. Which action should the nurse implement?

• A. Notify the healthcare provider
• B. Document that the pericarditis has resolved
• C. Ask the client to lean forward and listen again
• D. Prepare to insert a unilateral chest tube

Correct answer: C

Rationale: The correct action for the nurse to implement when unable to auscultate a pericardial friction rub in a client diagnosed with pericarditis is to ask the client to lean forward and listen again. Leaning forward can help bring the heart closer to the chest wall, making it easier to detect the rub. Option A (Notifying the healthcare provider) is incorrect because further assessment is needed before escalating the situation. Option B (Documenting that the pericarditis has resolved) is incorrect as the absence of a friction rub does not necessarily mean resolution. Option D (Preparing to insert a unilateral chest tube) is incorrect as this intervention is not indicated for the absence of a friction rub.

2. Clinitest is used in testing the urine of a client for glucose. Which of the following, if committed by a nurse, indicates an error?

• A. Specimen is collected after meals
• B. The nurse puts the clingiest tablet into a test tube
• C. She added 5 drops of urine and 10 drops of water
• D. If the color becomes orange or red, It is considered

Correct answer: C

Rationale: When conducting a Clinitest for testing urinary glucose levels, it is essential to add the correct amounts of urine and Clinitest reagent as instructed. Adding more water than urine could dilute the sample, leading to inaccurate test results. It's important to follow the correct ratio of drops specified in the instructions for an accurate reading.

3. 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.

4. For which client situation would a consultation with a rapid response team (RRT) be most appropriate?

• A. 45-year-old; 2 years post kidney transplant; second hospital day for treatment of pneumonia; no urine output for 6 hours; temperature 101.4°F; heart rate of 98 beats per minute; respirations 20 breaths per minute; blood pressure 88/72 mm Hg; is restless
• B. 72-year-old; 24 hours after removal of a chest tube that was used to drain pleural fluid (effusion); temperature 97.8°F; heart rate 92 beats per minute; respirations 28 breaths per minute; blood pressure 132/86 mm Hg; anxious about going home
• C. 56-year-old fourth hospital day after a coronary artery bypass procedure; sore chest; pain with walking temperature 97°F; heart rate 84 beats per minute; respirations 22 breaths per minute; blood pressure 87/72 mm Hg; bored with hospitalization.
• D. 86-year-old; 48 hours postoperative repair of a fractured hip (nail inserted; alert; oriented; using patient-controlled analgesia (PCA) pump; temperature 96.8°F; heart rate 60 beats per minute; respirations 16 breaths per minute; blood pressure 90/62 mm Hg; talking with daughter.

Correct answer: A

Rationale: A consultation with a Rapid Response Team (RRT) is most appropriate for the 45-year-old client described in Choice A. This client is 2 years post kidney transplant, presenting with no urine output for 6 hours, a temperature of 101.4°F, heart rate of 98 beats per minute, respirations of 20 breaths per minute, and a blood pressure of 88/72 mm Hg, along with restlessness. These clinical signs are indicative of possible acute renal failure and sepsis, requiring immediate intervention by the rapid response team. Choices B, C, and D do not present the same level of urgency and severity of symptoms as the client in Choice A, making them less appropriate for consultation with the RRT.

5. The nurse is preparing a postoperative nursing care plan for the client recovering from a hemorrhoidectomy. Which intervention should the nurse implement?

• A. Establish a rapport with the client to decrease embarrassment during site assessment
• B. Encourage the client to lie in the lithotomy position twice a day
• C. Milk the tube inserted during surgery to facilitate the passage of flatus
• D. Digitally dilate the rectal sphincter to express old blood

Correct answer: A

Rationale: Establishing rapport with the client is crucial in postoperative care to create a trusting relationship, reduce embarrassment, and enhance comfort during assessments. Encouraging the client to lie in the lithotomy position is not recommended after a hemorrhoidectomy as it can be uncomfortable and may disrupt wound healing. Milking the tube inserted during surgery is not a standard practice and could lead to complications. Digitally dilating the rectal sphincter is not indicated post-hemorrhoidectomy and can cause harm to the client.

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