Nursing Elites

1. The nurse determines that a postoperative client's respiratory rate has increased from 18 to 24 breaths/min. Based on this assessment finding, which intervention is most important for the nurse to implement?

• A. Encourage the client to increase ambulation in the room.
• B. Offer the client a high-carbohydrate snack for energy.
• C. Force fluids to thin the client's pulmonary secretions.
• D. Determine if pain is causing the client's tachypnea.

Correct answer: D

Rationale: When a postoperative client's respiratory rate increases, it is essential to determine the underlying cause. Pain, anxiety, and fluid accumulation in the lungs can lead to tachypnea (increased respiratory rate). Therefore, the priority intervention is to assess if pain is the contributing factor. Encouraging increased ambulation may worsen oxygen desaturation in a client with a rising respiratory rate. Offering a high-carbohydrate snack is not indicated as it can increase carbon metabolism; instead, consider providing an alternative energy source like Pulmocare liquid supplement. Forcing fluids may exacerbate respiratory congestion in a client with a compromised cardiopulmonary system, potentially leading to fluid overload. Therefore, determining the role of pain in tachypnea is crucial for appropriate management.

2. When performing a cultural assessment with a patient from a different culture, what action should the nurse take first?

• A. Request an interpreter before interviewing the patient
• B. Wait until a family member is available to help with the assessment
• C. Ask the patient about any affiliation with a particular cultural group
• D. Tell the patient what the nurse already knows about the patient's culture

Correct answer: B

Rationale: When conducting a cultural assessment, the first step is to inquire if the patient has any affiliation with a specific cultural group. This helps the nurse understand the patient's background and beliefs. Requesting an interpreter before interviewing the patient may be necessary if language barriers exist. Waiting for a family member to assist with the assessment may delay the process and compromise patient confidentiality. Telling the patient what the nurse knows about their culture assumes knowledge and may lead to misunderstandings or inaccuracies.

3. The wife of a client who is dying says, 'I want to see him, but I can only come twice a week because of work, household chores, and caring for our cat and dog.' Which defense mechanism is the wife using?

• A. Projection
• B. Sublimation
• C. Compensation
• D. Rationalization

Correct answer: D

Rationale: The wife is using rationalization as a defense mechanism. Rationalization involves offering a socially acceptable or logical explanation to justify an unacceptable feeling or behavior. In this scenario, the wife justifies her limited visits to her dying husband by citing other responsibilities such as work, household chores, and pet care. Projection involves denying one's unacceptable feelings and attributing them to others. Sublimation is the substitution of unacceptable feelings or drives with socially acceptable behaviors. Compensation involves making up for a perceived deficiency by emphasizing another perceived asset.

4. A client is undergoing treatment for alcoholism. Twelve hours after their last drink, they develop tremors, increased heart rate, hallucinations, and seizures. Which stage of withdrawal is this client experiencing?

• A. Stage 1
• B. Stage 2
• C. Stage 3
• D. Stage 4

Correct answer: C

Rationale: In alcohol withdrawal, stage 3 typically begins about 12-48 hours after the last drink. It includes symptoms from stages 1 and 2 like tremors, tachycardia, mild hallucinations, hyperactivity, and confusion. By stage 3, severe hallucinations and seizures can occur. Choice A, stage 1, is too early for the described symptoms. Stage 2, as described, is also too early as it typically occurs within 6-12 hours. Stage 4 is not a recognized stage in alcohol withdrawal protocols.

5. A neonate born at 32 weeks' gestation and weighing 3 lb (1361 g) is admitted to the neonatal intensive care unit (NICU). When would the nurse take the neonate's mother to visit the infant?

• A. When the infant's condition has stabilized
• B. When the infant is out of immediate danger
• C. When the primary health care provider has provided written permission
• D. When the mother is well enough to be taken to the NICU

Correct answer: D

Rationale: The mother should see her infant as soon as possible to acknowledge the reality of the birth and begin bonding. Delaying the visit may impede maternal-infant bonding. The timing of the mother's visit should be based on her physical and emotional readiness, not solely on the infant's condition or the need for written permission. The nurse can independently facilitate the mother's visit without requiring a prescription from the primary healthcare provider.

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