Nursing Elites

1. In providing comprehensive family health care, the nurse utilizes four (4) basic processes. These are listed in the order in which they are carried out as follows:

• A. assessment, planning, intervention, and evaluation
• B. assessment, intervention, planning, and evaluation
• C. planning, assessment, intervention, and evaluation
• D. planning, intervention, evaluation, and assessment

Correct answer: A

Rationale: The correct order for the basic processes in providing comprehensive family health care is assessment, planning, intervention, and evaluation. Assessment is the first step to gather information, followed by planning to set goals and strategies, then intervention to implement the plan, and finally evaluation to assess the outcomes. Choice A is correct as it follows this logical sequence. Choices B, C, and D are incorrect because they do not follow the correct order of these essential processes in nursing care.

2. The nurse is caring for a client with status epilepticus. The most important nursing assessment of this client is

• A. Intravenous fluid infusion
• B. Level of consciousness
• C. Pulse and respirations
• D. Extremities for injuries

Correct answer: B

Rationale: In status epilepticus, the most crucial nursing assessment is the level of consciousness. Assessing the client's level of consciousness is vital as prolonged seizures can result in hypoxia, brain damage, and require immediate intervention. Pulse and respirations (choice C) are important assessments, but in status epilepticus, the priority is to monitor the client's neurological status. Checking intravenous fluid infusion (choice A) and extremities for injuries (choice D) are not the primary assessments needed in managing a client experiencing status epilepticus.

3. Which of the following statements about CHN is wrong?

• A. CHN synthesizes public health with nursing
• B. CHN emphasizes health
• C. Promoting clients' autonomy is a responsibility of public nursing
• D. CHN makes a unique contribution to health care not by the nature of its practice but where it is practiced

Correct answer: D

Rationale: The statement in option D is incorrect. The unique contribution of Community Health Nursing (CHN) is not only where it is practiced but also by the nature of its practice. CHN's distinct value lies in its approach to care delivery, focusing on preventive care, health promotion, and addressing the needs of specific communities. Options A and B are correct as CHN involves synthesizing public health principles with nursing practice and emphasizes holistic health. Option C is incorrect as promoting clients' autonomy is a fundamental aspect of community health nursing, respecting individuals' rights to make decisions about their health.

4. Postoperative orders for a client undergoing a mitral valve replacement include monitoring pulmonary artery pressure together with pulmonary capillary wedge pressure with a pulmonary artery catheter. This action by the nurse will assess

• A. Right ventricular pressure
• B. Left ventricular end-diastolic pressure
• C. Acid-Base balance
• D. Coronary artery stability

Correct answer: B

Rationale: The correct answer is B: Left ventricular end-diastolic pressure. Pulmonary capillary wedge pressure is used to assess left ventricular end-diastolic pressure. This measurement provides valuable information on the filling pressure of the left ventricle. Choices A, C, and D are incorrect because monitoring pulmonary capillary wedge pressure does not directly assess right ventricular pressure, acid-base balance, or coronary artery stability.

5. In the immediate postoperative period for a cleft lip repair in a 2-month-old infant, which nursing approach should be the priority?

• A. Remove protective arm devices one at a time for short periods with supervision
• B. Initiate oral feedings when alert
• C. Introduce the parents to the suture line cleansing protocol
• D. Position the infant on the back after feedings throughout the day

Correct answer: A

Rationale: The correct nursing approach in the immediate postoperative period for a cleft lip repair in an infant is to remove protective arm devices one at a time for short periods with supervision. This approach helps prevent injury to the surgical site while ensuring the infant's comfort and safety. Choice B is incorrect as initiating oral feedings immediately after surgery may not be appropriate and could compromise the surgical site. Choice C is incorrect as introducing parents to the suture line cleansing protocol is important but not the immediate priority. Choice D is incorrect as positioning the infant on the back after feedings is not specific to the immediate postoperative period for a cleft lip repair.

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