Nursing Elites

1. After a client has a tubal ligation in the outpatient surgical clinic, what is the priority for the nurse to determine?

• A. The client's prior experiences with outpatient surgery
• B. The client's medical plan and the extent of coverage for outpatient surgery
• C. The client's plan for transportation and care at home
• D. The client's plan to spend the night at the surgical center

Correct answer: C

Rationale: The priority for the nurse is to ensure the client has a safe way to get home and adequate care after discharge. It is crucial to determine the client's transportation arrangements and availability of care at home to ensure a smooth transition postoperatively. Options A and B, though important, are not immediate priorities compared to the client's safety and well-being after the procedure. Option D is incorrect as spending the night at the surgical center is not typically part of the plan for outpatient surgery.

2. Which behavior by a new nurse would indicate to the charge nurse that this nurse is following standard precautions?

• A. Wearing clean gloves while performing a heel stick on an infant
• B. Wearing the same gloves for assessments of clients in the same room
• C. Wearing sterile gloves when changing the urine bag and nasogastric canister of an infected client
• D. Donning a gown when responding to a request by the family to check the IV pump on a client with rotavirus

Correct answer: A

Rationale: The correct answer is wearing clean gloves while performing a heel stick on an infant. Standard precautions require the use of gloves when there is a risk of exposure to blood or body fluids. Clean gloves are suitable for this task as they provide adequate protection without being sterile. Choice B is incorrect because wearing the same gloves for different clients can lead to cross-contamination, violating standard precautions. Choice C is incorrect as sterile gloves are usually not required for changing a urine bag and nasogastric canister unless a specific aseptic technique is indicated; standard precautions do not demand sterile gloves for such tasks. Choice D is incorrect as donning a gown is not necessary for checking an IV pump unless there is a risk of exposure to bodily fluids that would necessitate full-body protection, which is not indicated in this scenario.

3. The client with obsessive-compulsive disorder (OCD) is asking for help with the repetitive behaviors. The nurse knows that these are a method of dealing with:

• A. Fearful situations
• B. Depression
• C. Delusions
• D. Anxiety

Correct answer: D

Rationale: The correct answer is D: Anxiety. Repetitive behaviors in OCD serve as a way for individuals to cope with their anxiety. These behaviors are often performed to reduce the distress caused by obsessive thoughts. Choice A, fearful situations, is incorrect because the behaviors are more related to managing anxiety rather than fear itself. Choice B, depression, is incorrect as OCD behaviors are not typically a method of coping with depression. Choice C, delusions, is also incorrect as these behaviors are not aimed at managing delusional thoughts but rather anxiety in OCD.

4. The newborn nursery is filled to capacity. Which newborn should the nurse assess first?

• A. A three-hour-old just waking up after a period of sleep
• B. A two-day-old crying loudly
• C. A three-day-old two hours after circumcision
• D. A one-hour-old sucking his fist

Correct answer: A

Rationale: The most critical time for assessment in a newborn is during the second period of reactivity, which occurs approximately 3-5 hours after delivery. During this phase, newborns are more likely to gag on mucus and aspirate, making it crucial for the nurse to assess their respiratory status first. Choice A indicates a newborn in this critical phase, requiring immediate assessment for potential airway compromise or respiratory distress. Choices B, C, and D do not present an immediate need for assessment related to airway compromise or respiratory distress.

5. The nurse is checking laboratory values on a patient who has crackling rales in the lower lobes, 2+ pitting edema, and dyspnea with minimal exertion. Which of the following laboratory values does the nurse expect to be abnormal?

• A. Potassium.
• B. B-type natriuretic peptide (BNP).
• C. C-reactive protein (CRP).
• D. Platelets.

Correct answer: B

Rationale: The client's symptoms suggest heart failure. BNP is a neurohormone released from the ventricles due to increased pressure and stretch, as seen in heart failure. A BNP level greater than 51 pg/mL is often associated with mild heart failure, with higher levels indicating more severe heart failure. Potassium levels are not typically affected by heart failure. CRP is an inflammation indicator used to predict coronary artery disease risk, not directly related to heart failure in this case. The client's symptoms do not suggest bleeding or clotting abnormalities associated with platelet count issues, making platelets an unlikely abnormal value.

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