Nursing Elites

1. The student observes a patient with no breathing problems. Which action by the student indicates a need to review respiratory assessment skills?

• A. The student starts at the apices of the lungs and moves to the bases.
• B. The student compares breath sounds from side to side, avoiding bony areas.
• C. The student places the stethoscope over the posterior chest and listens during expiration.
• D. The student instructs the patient to breathe slowly and a little more deeply than normal through the mouth.

Correct answer: C

Rationale: The correct answer is C. Listening only during inspiration instead of both inspiration and expiration indicates a need for a review of respiratory assessment skills. During chest auscultation, it is essential to listen to at least one cycle of inspiration and expiration at each placement of the stethoscope. Instructing the patient to breathe slowly and a little deeper than normal through the mouth is a correct practice during auscultation. The correct sequence for lung auscultation is from the apices to the bases, comparing breath sounds bilaterally, avoiding bony areas. It is crucial to place the stethoscope over lung tissue rather than bony prominences to accurately assess lung sounds.

2. When percussing over the lungs of a 4-year-old child, the nurse hears bilateral loud, long, and low tones. How should the nurse proceed?

• A. Palpate over the area for increased pain and tenderness.
• B. Ask the child to take shallow breaths and percuss over the area again.
• C. Refer the child to a specialist because of an increased amount of air in the lungs.
• D. Consider this finding as normal for a child this age and proceed with the examination.

Correct answer: D

Rationale: In pediatric patients, loud, long, and low tones heard when percussing over the lungs are normal findings. These percussion notes are characteristic of a child's lung due to its thin chest wall and increased air content. It is unnecessary to palpate for pain and tenderness, ask the child to take shallow breaths and repeat the percussion, or refer the child to a specialist. Therefore, the correct action is to consider these findings as normal for the child's age and continue with the examination.

3. Which of the following tests would MOST LIKELY be performed on a patient who is being monitored for coagulation therapy?

• A. PT/INR
• B. CBC
• C. PTT
• D. WBC

Correct answer: A

Rationale: The correct answer is A: PT/INR. Prothrombin times (PT/INR) are commonly used to monitor patients on Coumadin (warfarin) therapy, an anticoagulant that slows the blood's ability to clot. Monitoring PT/INR levels helps ensure the patient is receiving the appropriate dosage of Coumadin. Choice B, CBC (Complete Blood Count), is a general test that provides information on red blood cells, white blood cells, and platelets but is not specific to monitoring coagulation therapy. Choice C, PTT (Partial Thromboplastin Time), is another coagulation test but is not as commonly used for monitoring Coumadin therapy. Choice D, WBC (White Blood Cell count), is unrelated to monitoring coagulation therapy and is used to assess immune system function.

4. What is the MOST ACCURATE statement regarding the ESR test?

• A. The results are diagnostic for certain conditions.
• B. Abnormal results are indicative of a potentially fatal illness.
• C. Abnormal results should be followed by additional testing.
• D. Results are reported in millimeters per hour.

Correct answer: C

Rationale: The erythrocyte sedimentation rate (ESR) is a non-specific screening test for inflammation in the body. It is not used as a definitive diagnostic tool for specific conditions. When ESR results are abnormal, they indicate the presence of inflammation, which can be caused by various reasons. Therefore, abnormal results should be followed by additional testing to determine the underlying cause. The ESR test measures the rate at which red blood cells settle in a vertical tube over the span of one hour, and results are reported in millimeters per hour. Choice A is incorrect because ESR results are not solely diagnostic for any specific condition. Choice B is incorrect as abnormal ESR results do not directly indicate a potentially fatal illness without further investigation. Choice D is incorrect as the results are reported in millimeters per hour, not per minute.

5. A client is suspected of having carbon monoxide poisoning. Which of the following symptoms are associated with this condition?

• A. Red rash across the trunk and extremities
• B. Nausea, vomiting, seizures
• C. Flushing of the face and neck
• D. Abdominal pain radiating to the back

Correct answer: B

Rationale: The correct answer is 'Nausea, vomiting, seizures.' Carbon monoxide poisoning can present with symptoms such as headache, dizziness, weakness, nausea, vomiting, and confusion. Severe cases can progress to seizures, coma, and even death. It is crucial for healthcare providers to recognize these symptoms promptly to initiate appropriate treatment. Choices A, C, and D are incorrect because a red rash, flushing of the face and neck, and abdominal pain radiating to the back are not typically associated with carbon monoxide poisoning. It is essential to be aware of the common manifestations of carbon monoxide poisoning to ensure timely intervention and prevent adverse outcomes.

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