Nursing Elites

1. The nurse palpates the posterior chest while the patient says 99 and notes absent fremitus. What action should the nurse take next?

• A. Auscultate anterior and posterior breath sounds bilaterally
• B. Encourage the patient to turn, cough, and deep breathe
• C. Review the chest x-ray report for evidence of pneumonia
• D. Palpate the anterior chest and observe for barrel chest

Correct answer: A

Rationale: To assess for tactile fremitus, the nurse should use the palms of the hands to assess for vibration when the patient repeats a word or phrase such as '99'. After noting absent fremitus, the nurse should then auscultate the lungs to assess for the presence or absence of breath sounds. Absent fremitus may be noted with conditions like pneumothorax or atelectasis. The vibration is increased in conditions such as pneumonia, lung tumors, thick bronchial secretions, and pleural effusion. Encouraging the patient to turn, cough, and deep breathe is an appropriate intervention for atelectasis, but assessing breath sounds takes priority. Fremitus is decreased if the hand is farther from the lung or the lung is hyperinflated (barrel chest). Palpating the anterior chest for fremitus is less effective due to the presence of large muscles and breast tissue, making auscultation a more appropriate next step.

2. Following surgery to correct cryptorchidism, what is the priority action that the nurse should include in the plan of care?

• A. Prevent tension on the suture.
• B. Monitor urine for glucose and acetone.
• C. Encourage oral fluids, and monitor intake and output.
• D. Encourage coughing and deep breathing every hour.

Correct answer: A

Rationale: The correct answer is to prevent tension on the suture. After surgery for cryptorchidism, the testicle is held in position by an internal suture that should not be dislodged. Immobilization of the area for a week is crucial to prevent complications like bleeding and infection. Monitoring urine for glucose and acetone is unrelated to this surgery. While maintaining hydration is important, forcing fluids is not necessary. Encouraging coughing and deep breathing every hour may be a postoperative consideration, but it is not the priority for this specific surgery.

3. A patient is admitted to the emergency department complaining of sudden onset shortness of breath and is diagnosed with a possible pulmonary embolus. How should the nurse prepare the patient for diagnostic testing to confirm the diagnosis?

• A. Start an IV so contrast media may be given
• B. Ensure that the patient has been NPO for at least 6 hours.
• C. Inform radiology that a radioactive glucose preparation is needed
• D. Instruct the patient to undress to the waist and remove any metal objects

Correct answer: A

Rationale: For diagnosing pulmonary emboli, spiral computed tomography (CT) scans are commonly used, and contrast media may be given intravenously (IV) during the scan to enhance visualization of blood vessels. Chest x-rays are not typically diagnostic for pulmonary embolism. When preparing for a chest x-ray, the patient needs to undress and remove any metal objects. Bronchoscopy is used for examining the bronchial tree, not for assessing vascular changes, and the patient should be NPO 6 to 12 hours before the procedure. Positron emission tomography (PET) scans are primarily used to detect malignancies, and a radioactive glucose preparation is utilized for this purpose.

4. A patient in the emergency room has a fractured left elbow and presents with an unequal radial pulse, swelling, and numbness in the left hand after waiting for 5 hours. What is the nurse's priority intervention?

• A. Place the patient in a supine position
• B. Ask the patient to rate his pain on a scale of 1 to 10.
• C. Wrap the fractured area with a snug dressing
• D. Start an IV in the other arm.

Correct answer: D

Rationale: The correct answer is to start an IV in the other arm. In this scenario, the patient is showing signs of Acute Compartment Syndrome, a serious condition that occurs due to increased pressure within a muscle compartment, leading to decreased blood flow and potential tissue damage. Starting an IV is crucial as the patient may require emergency surgery, such as a fasciotomy, to relieve the pressure and prevent further complications. Placing the patient in a supine position, asking about pain levels, or wrapping the fractured area, though important, are not the priority interventions in this critical situation where immediate medical intervention is necessary to prevent irreversible damage or loss of limb.

5. While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse's first action?

• A. Check vital signs.
• B. Massage the fundus.
• C. Offer a bedpan.
• D. Check for perineal lacerations.

Correct answer: B

Rationale: The nurse's first action should be to massage the fundus until it is firm as uterine atony is the primary cause of bleeding in the first hour after delivery. Massaging the fundus helps to stimulate uterine contractions, which can help control the bleeding. Checking vital signs would be important but addressing the primary cause of bleeding takes precedence. Offering a bedpan is not a priority in this situation as the focus should be on managing the postpartum bleeding. Checking for perineal lacerations is also important but not the initial action needed to address the boggy uterus and vaginal bleeding.

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