Nursing Elites

1. A man is receiving heparin subcutaneously. The patient has dementia and lives at home with a part-time caretaker. The nurse is most concerned about which side effect of heparin?

• A. Back Pain
• B. Fever and Chills
• C. Risk for Bleeding
• D. Dizziness

Correct answer: C

Rationale: The correct answer is 'Risk for Bleeding.' A patient with dementia may have impaired judgment and may be prone to falls or injuries, increasing the risk of bleeding while on heparin therapy. Monitoring for signs of bleeding is crucial in this situation. Choice A, 'Back Pain,' is not a common side effect of heparin. Choice B, 'Fever and Chills,' is not a typical side effect of heparin but may indicate other underlying conditions. Choice D, 'Dizziness,' is not a common side effect of heparin and is not the primary concern in this scenario.

2. 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.

3. One hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on a 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action is best for the nurse to take next?

• A. Milk the chest tube gently to remove any clots.
• B. Clamp the chest tube momentarily to check for the origin of the air leak.
• C. Assist the patient to deep breathe, cough, and use the incentive spirometer.
• D. Set up the patient-controlled analgesia (PCA) and administer the loading dose of morphine.

Correct answer: S

Rationale: In this scenario, the best action is to set up the patient-controlled analgesia (PCA) and administer the loading dose of morphine. The patient's pain level is high, which can hinder deep breathing and coughing. Addressing pain control is a priority to facilitate optimal respiratory function. Milking the chest tube to remove clots is unnecessary as the drainage amount is not alarming in the early postoperative period. Clamping the chest tube to locate the air leak is not recommended as it can lead to tension pneumothorax. Assisting the patient to deep breathe, cough, and use the incentive spirometer is important but should follow adequate pain management to ensure the patient can effectively participate in these activities.

4. To prevent a Valsalva maneuver in a client recovering from an acute myocardial infarction, the nurse would:

• A. Assist the client in using the bedside commode
• B. Administer stool softeners daily as prescribed
• C. Administer antidysrhythmics PRN as prescribed
• D. Maintain the client on strict bed rest

Correct answer: B

Rationale: Administering stool softeners daily as prescribed is essential to prevent straining during defecation, which can lead to a Valsalva maneuver. Straining can increase intra-abdominal pressure, hinder venous return, and elevate blood pressure, risking cardiac complications in a client recovering from a heart attack. Using a bedside commode might be useful to minimize exertion during toileting but does not directly address the risk of a Valsalva maneuver. Administering antidysrhythmics PRN is not the primary intervention for preventing a Valsalva maneuver; these medications are used to manage dysrhythmias if they occur. Keeping the client on strict bed rest is not the best option as early mobilization is encouraged in post-myocardial infarction recovery to prevent complications such as deep vein thrombosis and muscle weakness.

5. A nurse has just started her rounds delivering medication. A new patient on her rounds is a 4-year-old boy who is non-verbal. This child does not have any identification on. What should the nurse do?

• A. Contact the provider
• B. Ask the child to write their name on paper
• C. Ask a coworker about the identification of the child
• D. Ask the father who is in the room the child's name

Correct answer: D

Rationale: When encountering a non-verbal child without identification, it is appropriate for the nurse to ask the accompanying parent or guardian for the child's name. The father, being present in the room, can provide the necessary information. This ensures accurate identification to deliver the correct medication. Contacting the provider may cause unnecessary delays. Asking a non-verbal child to write their name is not feasible. Asking a coworker may not provide reliable identification as they may not have direct knowledge.

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