Nursing Elites

1. A healthcare professional is reviewing ABG laboratory results of a client who is in respiratory distress. The results are pH 7.47, PaCO2 32 mm Hg, and HCO3 22 mm Hg. The healthcare professional should recognize that the client is experiencing which of the following acid-base imbalances?

• A. Respiratory acidosis
• B. Respiratory alkalosis
• C. Metabolic acidosis
• D. Metabolic alkalosis

Correct answer: B

Rationale: The ABG results show a high pH (alkalosis) along with low PaCO2 and normal HCO3 levels, indicating respiratory alkalosis. In this condition, there is excessive loss of carbon dioxide (as seen by the low PaCO2) leading to a decrease in carbonic acid concentration and subsequent increase in pH. Metabolic acidosis or alkalosis would involve primary changes in bicarbonate levels, which are not predominant in this case.

2. Which of the following statements is incorrect about a patient with dysphagia?

• A. The patient will find pureed or soft foods, such as custards, easier to swallow than water
• B. Fowler’s or semi Fowler’s position reduces the risk of aspiration during swallowing
• C. The patient should always feed himself
• D. The nurse should perform oral hygiene before assisting with feeding

Correct answer: C

Rationale: The incorrect statement is that 'The patient should always feed himself.' Patients with dysphagia may require assistance with feeding due to difficulty in swallowing safely. It is essential to provide appropriate support and supervision during meal times to prevent complications such as aspiration or inadequate nutrition intake.

3. A healthcare professional is assessing a client who has a pulmonary embolism. Which of the following information should the healthcare professional not expect to find?

• A. Bradypnea
• B. Pleural friction rub
• C. Petechiae
• D. Tachycardia

Correct answer: A

Rationale: In a client with a pulmonary embolism, bradypnea, which is abnormally slow breathing, is not an expected finding. Pulmonary embolism typically presents with tachypnea (rapid breathing) due to the body's compensatory mechanism to increase oxygen levels. Pleural friction rub, petechiae, and tachycardia are commonly associated with a pulmonary embolism due to the impaired oxygenation and increased workload on the heart. Therefore, the healthcare professional should not expect to find bradypnea during the assessment of a client with a pulmonary embolism.

4. When a family of an accident victim, who has been declared brain-dead, appears open to organ donation, what should the nurse do?

• A. Discourage them from deciding until their grief has eased
• B. Listen to their concerns and answer their questions truthfully
• C. Urge them to immediately sign the consent form
• D. Inform them that the body will not be available for a wake or funeral

Correct answer: B

Rationale: In situations involving potential organ donation, the nurse's role is to provide support, listen to the family's concerns, and answer their questions truthfully. By doing so, the nurse can help facilitate an informed and respectful decision-making process for the grieving family.

5. When removing a contaminated gown, what should be the first thing touched by the nurse?

• A. Waist tie and neck tie at the back of the gown
• B. Waist tie in front of the gown
• C. Cuffs of the gown
• D. Inside of the gown

Correct answer: A

Rationale: When removing a contaminated gown, the nurse should ensure the first thing touched is the waist tie and neck tie at the back of the gown. This procedure helps prevent contamination by ensuring that the outer surface of the gown, which is likely to be contaminated, is not touched during removal. By touching the back ties first, the nurse minimizes the risk of transferring any contaminants to themselves or the environment.

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