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. Which of the following individuals is at the highest risk of suicide?

• A. An 80-year-old man who lost his wife last year
• B. A 36-year-old woman whose former neighbor committed suicide
• C. A 40-year-old married businessman
• D. A 46-year-old former alcoholic who has been sober for 12 years

Correct answer: A

Rationale: The correct answer is an 80-year-old man who lost his wife last year. Certain factors increase the risk of suicide, such as recent loss of a loved one, in this case, the man's wife. The elderly are a high-risk group due to factors like social isolation, physical health issues, and bereavement. While experiencing a loss can affect anyone, the combination of age, loss of a spouse, and the associated emotional impact elevates the risk significantly. The other choices are not at the highest risk of suicide. A former alcoholic who has been sober for 12 years has taken steps towards recovery, reducing the immediate risk. A 40-year-old married businessman and a 36-year-old woman whose former neighbor committed suicide do not have the same level of immediate risk as the elderly man who recently lost his wife.

3. The nurse plans to administer diazepam, 4 mg IV push, to a client with severe anxiety. How many milliliters should the nurse administer? (Round to the nearest tenth.)

• A. 0.2 mL
• B. 0.8 mL
• C. 1.25 mL
• D. 2.0 mL

Correct answer: B

Rationale: To calculate the volume to administer, use the formula: (Volume to administer = (Ordered Dose × Volume on hand) / Dose on hand). In this case, it would be (4 mg × 1 mL) / 5 mg = 0.8 mL. Therefore, the nurse should administer 0.8 mL of diazepam. Choice A (0.2 mL) is incorrect because it miscalculates the dosage. Choice C (1.25 mL) and Choice D (2.0 mL) are incorrect as they do not align with the correct calculation based on the ordered dose and available concentration. The correct answer, 0.8 mL, is derived from accurate dosage calculation and aligns with the formula for IV medication administration, ensuring the safe and effective delivery of the medication to the client.

4. A female adolescent has anorexia nervosa and is malnourished and severely underweight. Which statement indicates that she is experiencing secondary gains from her behavior?

• A. "I'm huge; I'm as big as a house."
• B. "I get straight A's in all my subjects."
• C. "My mother keeps trying to get me to eat."
• D. "My hair is beginning to fall out in clumps."

Correct answer: C

Rationale: The statement "My mother keeps trying to get me to eat" indicates that the adolescent is experiencing secondary gains from her behavior. This is because the behavior has garnered attention from her mother, providing a sense of power and control, which are considered secondary gains. The statement "I'm huge; I'm as big as a house" reflects a disturbed body perception and is not related to secondary gains. Getting straight A's in all subjects is an achievement but not a secondary gain related to anorexia nervosa. The hair falling out in clumps is a physical consequence of starvation, not a secondary gain.

5. Which of the following actions is most appropriate when working with a client who is extremely angry?

• A. Place a light hand on the client's shoulder to convey understanding
• B. Maintain close proximity to build trust
• C. Temporarily change the subject if the client's behavior is escalating
• D. Close the door to the room to ensure privacy

Correct answer: C

Rationale: When dealing with an angry client, it is crucial to employ techniques that can help de-escalate the situation or ensure safety while providing care. If the client's behavior is escalating or they are fixating on a particular topic that is fueling their anger, it is advisable to temporarily change the subject. This technique can serve as a distraction from the initial trigger, allowing the client to refocus their thoughts and emotions. Placing a hand on the client's shoulder may not be well-received as physical touch can escalate the situation. Maintaining close proximity might be perceived as confrontational rather than building trust. Closing the door for privacy is important but may not directly address the client's anger or help in de-escalation.

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