Nursing Elites

1. The patient is being taught about pulmonary function testing (PFT). Which statement made by the patient indicates effective teaching?

• A. I will use my inhaler right before the test.
• B. I won't eat or drink anything 8 hours before the test.
• C. I should inhale deeply and blow out as hard as I can during the test.
• D. My blood pressure and pulse will be checked every 15 minutes after the test.

Correct answer: C

Rationale: The correct answer is 'I should inhale deeply and blow out as hard as I can during the test.' This statement indicates effective teaching because for PFT, the patient needs to inhale deeply and exhale forcefully. This maneuver helps in assessing lung function accurately. Choices A, B, and D are incorrect. Using an inhaler right before the test may alter the test results, which is not recommended. Fasting for 8 hours is not necessary for a PFT, and checking blood pressure and pulse every 15 minutes after the test is not part of the PFT procedure.

2. The parents of a child with a hernia are instructed by the nurse on measures to reduce the hernia. Which statement indicates the parents understand the care for their child?

• A. We will encourage our child to cough every few hours on a daily basis.
• B. We will make sure that our child participates in physical activity every day.
• C. We will provide comfort measures to reduce any crying periods by our child.
• D. We will be sure to give our child a Fleet enema every day to prevent constipation.

Correct answer: C

Rationale: The correct answer is providing comfort measures to reduce any crying periods by the child. This can include offering a warm bath, avoiding upright positioning, and using other comfort measures to reduce crying, which can help reduce a hernia. Encouraging coughing or physical activity can increase strain on the hernia. Giving a Fleet enema daily for constipation is not recommended as it can also increase strain on the hernia.

3. Which finding would necessitate an immediate change in the therapeutic plan for a patient with grade 2 hepatic encephalopathy?

• A. Weight loss of 2 lb (1 kg)
• B. Positive urine pregnancy test
• C. Hemoglobin level of 10.4 g/dL
• D. Complaints of nausea and anorexia

Correct answer: B

Rationale: A positive urine pregnancy test would require an immediate change in the therapeutic plan for a patient with grade 2 hepatic encephalopathy due to the teratogenic effects of ribavirin. Ribavirin needs to be discontinued immediately to prevent harm to the fetus. The other options, weight loss, hemoglobin level, and complaints of nausea and anorexia, are common adverse effects of the prescribed regimen and may necessitate interventions such as patient education or supportive care, but they would not mandate an immediate cessation of therapy as in the case of a positive pregnancy test.

4. A nurse is caring for a patient with peripheral vascular disease (PVD). The patient complains of burning and tingling of the hands and feet and cannot tolerate touch of any kind. Which of the following is the most likely explanation for these symptoms?

• A. Inadequate tissue perfusion leading to nerve damage.
• B. Fluid overload leading to compression of nerve tissue.
• C. Sensation distortion due to psychiatric disturbance.
• D. Inflammation of the skin on the hands and feet.

Correct answer: A

Rationale: Patients with the peripheral vascular disease often sustain nerve damage as a result of inadequate tissue perfusion. Ischemic rest pain is more worrisome; it refers to pain in the extremity that is due to a combination of PVD and inadequate perfusion. Ischemic rest pain often is exacerbated by poor cardiac output. The condition is often partially or fully relieved by placing the extremity in a dependent position, so that perfusion is enhanced by the effects of gravity.

5. The healthcare provider is educating a parent about side effects of routine immunizations. Which of the following must be reported immediately?

• A. Irritability
• B. Slight edema at the injection site
• C. Local tenderness
• D. Temperature of 102.5?F

Correct answer: D

Rationale: A temperature of 102.5�F or higher following immunization is considered an adverse reaction and should be reported immediately. This could indicate a more serious systemic response to the vaccine. Irritability, slight edema at the injection site, and local tenderness are common, mild side effects of routine immunizations and do not typically require immediate reporting. Other reactions that should be reported immediately include excessive crying for more than 3 hours, seizure activity, and the presence of tender, swollen, or reddened areas at the injection site.

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