Nursing Elites

1. Identifying the strengths and weaknesses in the nursing care plan is part of which of the following steps in determining and fulfilling the patient's nursing care needs?

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

Correct answer: A

Rationale: Correct. Evaluation involves assessing the effectiveness of the nursing care plan by identifying its strengths and weaknesses. This step helps in determining if the plan is meeting the patient's needs. Choice B (Planning) is incorrect because planning involves developing the nursing care plan based on the assessment of the patient's needs. Choice C (Implementation) is incorrect as it refers to putting the nursing care plan into action. Choice D (Assessment) is incorrect as assessment is the initial step in the nursing process, involving data collection and analysis to identify the patient's needs.

2. The nurse is caring for clients on a medical floor. Which client will the nurse assess first?

• A. The client with an abdominal aortic aneurysm who is constipated
• B. The client on bed rest who ambulated to the bathroom
• C. The client with essential hypertension who has epistaxis and a headache
• D. The client with arterial occlusive disease who has a decreased pedal pulse

Correct answer: C

Rationale: The correct answer is C because epistaxis and headache in a client with hypertension are signs of a hypertensive crisis, requiring immediate intervention. Option A is incorrect as constipation in a client with an abdominal aortic aneurysm, though important, does not indicate an immediate need for assessment. Option B, a client on bed rest who ambulated to the bathroom, does not present with urgent signs or symptoms requiring immediate assessment. Option D, a client with arterial occlusive disease and a decreased pedal pulse, needs attention but is not the priority compared to a hypertensive crisis with epistaxis and headache.

3. The client with peripheral venous disease is scheduled to go to the whirlpool for a dressing change. Which is the nurse’s priority intervention?

• A. Escort the client to the physical therapy department
• B. Medicate the client 30 minutes before going to the whirlpool
• C. Obtain the sterile dressing supplies for the client
• D. Assist the client to the bathroom prior to the treatment

Correct answer: B

Rationale: The correct answer is B. Pain management is essential before the procedure to ensure the client’s comfort and cooperation during the dressing change. Escorting the client to the physical therapy department (choice A) is not the priority at this time. While obtaining sterile dressing supplies (choice C) is important, ensuring pain management takes precedence. Assisting the client to the bathroom (choice D) is not directly related to the priority intervention of pain management before the whirlpool treatment.

4. The nurse is preparing to assist in examining a Hispanic child who was brought to the clinic by the mother. During the assessment of the child, the nurse should take which action(s)?

• A. Building rapport with the child
• B. Taking the child’s temperature
• C. A, D
• D. Obtaining an interpreter if necessary

Correct answer: C

Rationale: Building rapport with the child is essential to establish trust and cooperation during the assessment. Admiring the child may not be appropriate in a professional setting and might not contribute significantly to the assessment. Taking the child's temperature is a routine part of the assessment but may not be the most critical action in this scenario. Obtaining an interpreter is crucial to ensure effective communication between the healthcare team and the child and their mother, especially considering potential language barriers.

5. Which of the following nursing interventions is important for a client scheduled to have a Guaiac Test?

• A. Avoid turnips, radish, and horseradish 3 days before
• B. Continue iron preparation to prevent further loss of iron
• C. Do not consume red meat 12 hours before the procedure
• D. Encourage consumption of dark-colored foods with caffeine

Correct answer: A

Rationale: The correct answer is A. Turnips, radish, and horseradish are known to cause false-positive results in a Guaiac Test, which is used to detect blood in the stool. Avoiding these foods is crucial to ensure accurate test results. Choice B is incorrect because iron preparations can interfere with the test results. Choice C is incorrect as red meat does not impact the Guaiac Test significantly. Choice D is incorrect as caffeine and dark-colored foods are not relevant to the preparation for a Guaiac Test.

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