Nursing Elites

1. Which outcome should the nurse identify for the client diagnosed with fluid volume excess?

• A. The client will void a minimum of 30 mL per hour
• B. The client will have elastic skin turgor
• C. The client will have no adventitious breath sounds
• D. The client will have a serum creatinine of 1.4 mg/dL

Correct answer: C

Rationale: The correct outcome for a client diagnosed with fluid volume excess is the absence of adventitious breath sounds. This indicates that fluid is not accumulating in the lungs, a crucial sign in managing fluid volume excess. Choices A, B, and D are incorrect because voiding a specific amount of urine, having elastic skin turgor, and a serum creatinine level do not directly relate to managing fluid volume excess.

2. 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 when assessing the site
• B. Encourage the client to lie in the lithotomy position twice a day
• C. Milk the tube inserted during surgery to allow the passage of flatus
• D. Digitally dilate the rectal sphincter to express old blood

Correct answer: A

Rationale: Establishing rapport with the client is essential in postoperative care to create a trusting relationship, decrease embarrassment, and improve the client's comfort during assessments. Choice B is incorrect because the lithotomy position is not typically recommended post-hemorrhoidectomy. Choice C is incorrect because milking the tube inserted during surgery is not a standard practice after a hemorrhoidectomy. Choice D is incorrect as digitally dilating the rectal sphincter can cause harm and is not a part of routine post-hemorrhoidectomy care.

3. Which of the following is a nonmedical member of a unit who receives additional training in providing care beyond basic first aid procedures?

• A. Area support squad leader
• B. ATLS specialist
• C. Tactical lifesaver
• D. Combat lifesaver

Correct answer: D

Rationale: The correct answer is D, 'Combat lifesaver.' A Combat Lifesaver is a nonmedical member of a unit who is trained in advanced first aid procedures, providing care beyond basic first aid. Choice A, 'Area support squad leader,' does not specifically refer to someone trained in providing advanced care. Choice B, 'ATLS specialist,' refers to someone trained in Advanced Trauma Life Support (ATLS), which is beyond the scope of the question. Choice C, 'Tactical lifesaver,' is not a recognized term for the role described in the question.

4. Why may patients with hiatal hernia develop anemia?

• A. Iron absorption is reduced
• B. Gastritis may cause bleeding
• C. Iron stores turn over more quickly
• D. Patients have an aversion to foods that are good sources of iron

Correct answer: B

Rationale: The correct answer is B: Gastritis may cause bleeding. In patients with hiatal hernia, gastritis can lead to gastrointestinal bleeding, resulting in anemia due to blood loss. Choice A is incorrect because hiatal hernia does not directly affect iron absorption. Choice C is incorrect as iron stores turning over more quickly is not a typical reason for anemia in hiatal hernia patients. Choice D is incorrect as an aversion to iron-rich foods does not directly cause anemia in this context.

5. 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 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 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: The correct answer is A. This client situation presents with concerning clinical signs such as no urine output post kidney transplant, elevated temperature, tachycardia, hypotension, and restlessness, suggestive of acute renal failure and sepsis. These signs necessitate immediate intervention by the rapid response team (RRT) to address the potentially life-threatening conditions. Choice B is incorrect as the client is stable after chest tube removal and primarily anxious about going home. Choice C is incorrect as the client's symptoms are related to postoperative recovery and boredom, not indicating an urgent need for RRT consultation. Choice D is incorrect as the client post hip repair is stable, alert, and interacting normally, without signs of acute deterioration requiring RRT involvement.

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