Nursing Elites

1. Which term is best described as a systematic, rational method of planning and providing nursing care for individuals, families, groups, and communities?

• A. Assessment
• B. Nursing Process
• C. Diagnosis
• D. Implementation

Correct answer: B

Rationale: The correct answer is B: Nursing Process. The nursing process is a systematic, rational method that guides nurses in planning and delivering patient care. It involves a series of steps including assessment, diagnosis, planning, implementation, and evaluation. By utilizing the nursing process, nurses can provide individualized care tailored to the specific needs of patients, families, groups, and communities. Choice A, Assessment, is a step within the nursing process but does not encompass the entire process itself. Choice C, Diagnosis, is another step within the nursing process and focuses on identifying the patient's health problems. Choice D, Implementation, is also a step in the nursing process where the care plan is put into action, but it does not solely describe the entire systematic and rational method of planning and providing nursing care.

2. What is required for effective hand washing?

• A. Soap or detergent to promote emulsification
• B. Hot water to destroy bacteria
• C. A disinfectant to increase surface tension
• D. All of the above

Correct answer: A

Rationale: To effectively wash hands, soap or detergent is essential as they help emulsify fats and oils, allowing them to be rinsed away. Hot water alone cannot effectively destroy bacteria, and a disinfectant is not typically required for routine hand washing.

3. Prior to a thoracentesis, which of the following actions should the nurse take?

• A. Position the client in an upright position, leaning over the bedside table.
• B. Explain the procedure.
• C. Obtain ABGs.
• D. Administer benzocaine spray.

Correct answer: A

Rationale: Positioning the client in an upright position, leaning over the bedside table helps to facilitate access to the thoracic cavity during the thoracentesis procedure. This position allows for easier identification and access to the insertion site. Explaining the procedure to the client is important, but positioning is the priority. Obtaining ABGs is not directly related to the thoracentesis procedure. Administering benzocaine spray is not a standard practice before a thoracentesis.

4. A client is being assessed by a nurse who is 30 minutes postoperative following an arterial thrombectomy. Which of the following findings should the nurse report?

• A. Chest pain
• B. Muscle spasms
• C. Cool, moist skin
• D. Incisional pain

Correct answer: A

Rationale: Chest pain is a critical finding postoperatively, especially after an arterial thrombectomy, as it could indicate complications like myocardial infarction or pulmonary embolism. It requires immediate attention and further evaluation. Muscle spasms, cool moist skin, and incisional pain are important to assess but not as urgent as chest pain in this scenario.

5. A client has a new prescription for heparin therapy. Which of the following statements by the client should indicate an immediate concern for the nurse?

• A. ''I am allergic to morphine.''
• B. ''I take antacids several times a day.''
• C. ''I had a blood clot in my leg several years ago.''
• D. ''It hurts to take a deep breath.''

Correct answer: B

Rationale: The correct answer is the statement 'I take antacids several times a day.' Antacids can alter the absorption of heparin, potentially affecting its effectiveness and increasing the risk of clot formation. This is a significant concern as it can impact the therapeutic outcome of heparin therapy. The other statements are not directly related to potential complications or interactions with heparin therapy.

Similar Questions