Nursing Elites

1. A healthcare professional is reviewing the health records of five clients. Which of the following clients is not at risk for developing acute respiratory distress syndrome?

• A. A client who experienced a near-drowning incident
• B. A client following coronary artery bypass graft surgery
• C. A client who has a hemoglobin of 15.1 g/dL
• D. A client who has dysphagia

Correct answer: C

Rationale: Acute respiratory distress syndrome (ARDS) is a severe lung condition that can be triggered by various factors such as near-drowning incidents, surgeries like coronary artery bypass graft, and underlying conditions like dysphagia. Hemoglobin levels do not directly influence the risk of developing ARDS. A hemoglobin level of 15.1 g/dL falls within the normal range and does not predispose an individual to ARDS.

2. Before rigor mortis occurs, what is the nurse responsible for?

• A. Providing a complete bath and dressing change
• B. Placing one pillow under the body’s head and shoulders
• C. Removing the body’s clothing and wrapping the body in a shroud
• D. Allowing the body to relax normally

Correct answer: B

Rationale: Before rigor mortis occurs, the nurse is responsible for placing a pillow under the body's head and shoulders. This action helps maintain proper positioning, prevent postmortem changes, and ensure a dignified appearance. Providing a complete bath and dressing change, removing clothing, or wrapping the body in a shroud are tasks typically performed after rigor mortis sets in or later in the postmortem care process. Allowing the body to relax normally does not address the immediate need for proper positioning before rigor mortis occurs.

3. Which of the following white blood cell (WBC) counts clearly indicates leukocytosis?

• A. 4,500/mm³
• B. 7,000/mm³
• C. 10,000/mm³
• D. 25,000/mm³

Correct answer: D

Rationale: Leukocytosis is defined as an increase in the total white blood cell count. A normal WBC count typically ranges from 4,500 to 10,000/mm³. A WBC count of 25,000/mm³, as indicated in choice D, is significantly higher than the normal range and clearly indicates leukocytosis.

4. A client has a new diagnosis of tuberculosis and has been placed on a multi-medication regimen. Which of the following instructions should the nurse give the client related to ethambutol?

• A. Your urine can turn a dark orange.
• B. Watch for a change in the sclera of your eyes.
• C. Watch for any changes in vision.
• D. Take vitamin B6 daily.

Correct answer: C

Rationale: Ethambutol is associated with potential vision changes, including optic neuritis. Patients should be instructed to report any visual disturbances immediately to prevent permanent vision loss. Monitoring for changes in vision is crucial to detect any adverse effects early on and prevent serious complications.

5. The physician orders the administration of high-humidity oxygen by face mask and placement of the patient in a high Fowler’s position. After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. Which of the following nursing interventions has the greatest potential for improving this situation?

• A. Encourage the patient to increase her fluid intake to 200 ml every 2 hours
• B. Place a humidifier in the patient’s room
• C. Continue administering oxygen by high humidity face mask
• D. Perform chest physiotherapy on a regular schedule

Correct answer: D

Rationale: Chest physiotherapy is the most effective intervention in cases of impaired gas exchange related to increased secretions. This technique helps mobilize and clear secretions from the airways, thereby improving gas exchange in the lungs. Placing a humidifier or administering oxygen by high humidity face mask may provide moisture but may not directly address the clearance of secretions. Encouraging increased fluid intake can help with hydration but may not address the underlying issue of impaired gas exchange due to secretions.

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