Nursing Elites

1. When evaluating care of an immobilized patient, which action will the nurse take?

• A. Focus on whether the interdisciplinary team is satisfied with the care.
• B. Compare the patient's actual outcomes with the outcomes in the care plan.
• C. Involve primarily the patient's family and health care team to determine goal achievement.
• D. Use objective data solely in determining whether interventions have been successful.

Correct answer: B

Rationale: When evaluating the care of an immobilized patient, the nurse should focus on assessing outcomes and response to nursing care. By comparing the patient's actual outcomes with the outcomes identified during planning, the nurse can determine the effectiveness of the interventions implemented. This process allows for a comprehensive evaluation of the care provided. Choice A is incorrect because the satisfaction of the interdisciplinary team does not directly reflect the patient's outcomes and response to care. Choice C is incorrect as it mainly focuses on the involvement of the patient's family and healthcare team, which may not provide a holistic evaluation of the patient's care. Choice D is incorrect as relying solely on objective data may lead to overlooking important subjective aspects of the patient's response and outcomes, which are also crucial in evaluating care effectively.

2. A client who is postoperative and has paralytic ileus is being cared for by a nurse. Which of the following abdominal assessments should the nurse expect?

• A. Absent bowel sounds with distention
• B. Hyperactive bowel sounds
• C. Normal bowel sounds
• D. High-pitched bowel sounds

Correct answer: A

Rationale: In a client with paralytic ileus, absent bowel sounds with distention are expected due to decreased or absent bowel motility. This is a key characteristic of paralytic ileus, where the bowel is unable to contract and move contents along the digestive tract. Hyperactive bowel sounds (choice B) are more indicative of increased peristalsis, which is not typically seen in paralytic ileus. Normal bowel sounds (choice C) may not be present in a client with paralytic ileus. High-pitched bowel sounds (choice D) are not typically associated with paralytic ileus. Therefore, the correct assessment finding in this scenario is absent bowel sounds with distention.

3. When planning to insert a peripheral IV catheter for an older adult client, which of the following actions should the nurse plan to take?

• A. Insert the catheter at a 45° angle
• B. Place the client's arm in a dependent position
• C. Shave excess hair from the insertion site
• D. Initiate IV therapy in the veins of the hand

Correct answer: B

Rationale: Placing the client's arm in a dependent position is the correct action when inserting a peripheral IV catheter for an older adult client. This position helps veins dilate due to gravity, facilitating easier insertion of the IV catheter. Choice A is incorrect because catheters are typically inserted at a lower angle, around 10-30 degrees. Choice C is unnecessary unless excessive hair impedes the insertion process. Choice D is incorrect as veins in the hand are generally smaller and more prone to complications, making them less ideal for IV therapy in older adults.

4. Nurse talking with a client’s partner. She is having frustrations about managing responsibilities and care. What type of role performance stress is this?

• A. Role overload
• B. Role conflict
• C. Role ambiguity
• D. Role strain

Correct answer: A

Rationale: Role overload occurs when a person feels overwhelmed by the demands placed upon them.

5. A healthcare professional is reviewing the medical record of a client who has hypocalcemia. The healthcare professional should identify which of the following findings as a risk factor for the development of this electrolyte imbalance?

• A. Crohn’s disease
• B. Postoperative status following appendectomy
• C. History of bone cancer
• D. Hyperthyroidism

Correct answer: A

Rationale: Crohn’s disease is known to impair calcium absorption, which can lead to hypocalcemia. This condition affects the intestines and can disrupt the normal absorption of nutrients, including calcium. Postoperative status following appendectomy, history of bone cancer, and hyperthyroidism are typically not directly associated with a higher risk of developing hypocalcemia compared to Crohn’s disease.

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