Nursing Elites

1. A patient who has a history of chronic obstructive pulmonary disease (COPD) was hospitalized for increasing shortness of breath and chronic hypoxemia (SaO2 levels of 89% to 90%). In planning for discharge, which action by the nurse will be most effective in improving compliance with discharge teaching?

• A. Start giving the patient discharge teaching on the day of discharge
• B. Have the patient repeat the instructions immediately after teaching
• C. Accomplish the patient teaching just before the scheduled discharge
• D. Arrange for the patient's caregiver to be present during the teaching

Correct answer: D

Rationale: Hypoxemia interferes with the patient's ability to learn and retain information, so having the patient's caregiver present will increase the likelihood that discharge instructions will be followed. Having the patient repeat the instructions will indicate that the information is understood at the time, but it does not guarantee retention of the information. Giving discharge instructions just before discharge is not ideal as the patient is likely to be distracted and anxious at that time. Teaching the patient about discharge on the day of admission is not recommended because the patient may be more hypoxemic and anxious than usual, making it difficult for them to absorb and retain the information effectively. Therefore, arranging for the patient's caregiver to be present during the teaching session is the best option to ensure proper compliance and understanding of the discharge instructions.

2. The nurse is caring for a patient in the ICU who has had a spinal cord injury. She observes that his last blood pressure was 100/55, and his pulse is 48. These have both trended downwards from the baseline. What should the nurse expect to be the next course of action ordered by the physician?

• A. Assess the patient for decreased level of consciousness
• B. Administer Normal Saline
• C. Insert an NG Tube
• D. Connect and read an EKG

Correct answer: B

Rationale: The patient is entering neurogenic shock due to the spinal cord injury, leading to hypotension and bradycardia. Administering Normal Saline is essential to replace fluid volume, which can help in treating the hypotension and bradycardia symptomatically. This intervention aims to stabilize the patient's cardiovascular status. Assessing for decreased level of consciousness (Choice A) may be important but addressing the hemodynamic instability takes precedence. Inserting an NG Tube (Choice C) and connecting and reading an EKG (Choice D) are not the immediate actions required for the presenting symptoms of hypotension and bradycardia.

3. The nurse notes that a patient has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which action should the nurse take first?

• A. Assist the patient to sit upright in a chair.
• B. Splint the patient's chest during coughing.
• C. Medicate the patient with prescribed morphine.
• D. Observe the patient use the incentive spirometer.

Correct answer: C

Rationale: The correct answer is to medicate the patient with prescribed morphine. A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain, which can worsen with deep breathing and coughing. The priority is to address the incisional pain to facilitate effective coughing and deep breathing, which are essential for clearing the airways and preventing complications. Assisting the patient to sit upright, splinting the patient's chest during coughing, and observing the patient using the incentive spirometer are all appropriate interventions to improve airway clearance, but they should be implemented after addressing the incisional pain with medication.

4. When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient?

• A. Emergency pericardiocentesis
• B. Stabilization of the chest wall with tape
• C. Administration of an inhaled bronchodilator
• D. Insertion of a chest tube with a chest drainage system

Correct answer: D

Rationale: The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage. Emergency pericardiocentesis is not indicated as the patient's symptoms are not suggestive of cardiac tamponade. Stabilization of the chest wall with tape would not address the underlying issue of a potential pneumothorax or hemothorax. Administration of an inhaled bronchodilator is not appropriate in this scenario as the patient is not exhibiting signs of asthma or bronchoconstriction. Therefore, the correct intervention for this patient is the insertion of a chest tube with a chest drainage system to address the potential pneumothorax or hemothorax.

5. A client with schizophrenia is receiving Haloperidol (Haldol) 5 mg t.i.d.. The client's family is alarmed and calls the clinic when 'his eyes rolled upward.' The nurse recognizes this as what type of side effect?

• A. Oculogyric crisis
• B. Tardive dyskinesia
• C. Nystagmus
• D. Dysphagia

Correct answer: A

Rationale: Oculogyric crisis is a known side effect of antipsychotic medications like Haloperidol (Haldol) and is characterized by involuntary upward deviation of the eyes. This condition can be distressing to both the client and their family. Tardive dyskinesia (Choice B) is a different side effect characterized by repetitive, involuntary movements, especially of the face and tongue, which can occur with long-term antipsychotic use. Nystagmus (Choice C) is an involuntary eye movement that is rhythmic and can occur for various reasons but is not specific to Haloperidol use. Dysphagia (Choice D) refers to difficulty swallowing and is not typically associated with the use of Haloperidol.

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