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 principles of primary nursing has proven most satisfying to the patient and nurse?

• A. Continuity of patient care promotes efficient and cost-effective nursing care.
• B. Autonomy and authority for planning are best delegated to a nurse who knows the patient well.
• C. Accountability is clearest when one nurse is responsible for the overall plan and its implementation.
• D. The holistic approach provides for a therapeutic relationship, continuity, and efficient nursing care.

Correct answer: D

Rationale: The holistic approach, encompassing a therapeutic relationship, continuity, and efficient nursing care, is the most satisfying principle of primary nursing. This approach considers the patient as a whole, taking into account physical, emotional, social, and spiritual aspects, which enhances the nurse-patient relationship and promotes comprehensive care. It emphasizes individualized care delivery, continuity of care, and an integrated approach, leading to improved patient satisfaction and nurse fulfillment.

3. When caring for a client who speaks a language different from their own, what action should the nurse take?

• A. Request an interpreter of a different sex from the client.
• B. Request a family member or friend to interpret information for the client.
• C. Direct attention toward the interpreter when speaking to the client.
• D. Review the facility policy about the use of an interpreter.

Correct answer: D

Rationale: When caring for a client who speaks a different language, it is essential for the nurse to review the facility policy about the use of an interpreter. Using a professional interpreter ensures accurate communication and protects the client's confidentiality. Requesting an interpreter of a specific sex or relying on family members or friends can lead to miscommunication or breaches of confidentiality. Directing attention towards the interpreter helps facilitate communication but does not address the need for a professional interpreter as per facility policy.

4. A client is being instructed on how to perform pursed-lip breathing. Which of the following should be included in the plan of care?

• A. Take quick breaths upon inhalation.
• B. Place your hand over your stomach.
• C. Take a deep breath in through your nose.
• D. Puff your cheeks upon exhalation.

Correct answer: C

Rationale: Pursed-lip breathing is a breathing technique that involves inhaling slowly through the nose and exhaling gently through pursed lips. This technique helps improve breathing efficiency and can be beneficial for individuals with respiratory conditions. Instructing the client to take a deep breath in through the nose is essential for proper execution of pursed-lip breathing, making choice C the correct answer.

5. What is the primary goal of performing a bed bath?

• A. To cleanse, refresh, and provide comfort to the client who must remain in bed
• B. To expose the necessary parts of the body
• C. To develop skills in bed bath
• D. To check the body temperature of the client in bed

Correct answer: A

Rationale: The primary goal of performing a bed bath is to cleanse, refresh, and provide comfort to clients who are unable to leave their bed. This helps maintain their hygiene, promotes skin health, and enhances their overall well-being. Choice B is incorrect as the primary purpose is not to expose body parts but to provide hygiene and comfort. Choice C is incorrect as the main goal is client care, not skill development. Choice D is incorrect as checking body temperature is not the main purpose of a bed bath.

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