Nursing Elites

1. How does the pain of a myocardial infarction (MI) differ from stable angina?

• A. Accompanied by shortness of breath
• B. Feelings of fear or anxiety
• C. Lasts less than 15 minutes
• D. No relief from taking nitroglycerin

Correct answer: C

Rationale: The pain of a myocardial infarction (MI) is often accompanied by shortness of breath and feelings of fear or anxiety. Unlike stable angina, the pain of an MI typically lasts longer than 15 minutes and is not relieved by nitroglycerin. Additionally, it can occur without a known cause, unlike stable angina which often has a trigger such as exertion.

2. A client just had a flexible bronchoscopy. Which of the following nursing actions is appropriate?

• A. Withhold food and liquids until the client’s gag reflex returns.
• B. Irrigate the client’s throat every 4 hours.
• C. Have the client refrain from talking for 24 hours.
• D. Suction the client’s oropharynx frequently.

Correct answer: Withhold food and liquids until the client’s gag reflex returns.

Rationale: After a flexible bronchoscopy, it is crucial to withhold food and liquids until the client's gag reflex returns to prevent aspiration. Irrigating the client's throat every 4 hours, having the client refrain from talking for 24 hours, and frequent suctioning of the oropharynx are not indicated post-bronchoscopy and may even pose risks to the client's recovery.

3. How does the pain of a myocardial infarction (MI) differ from stable angina? (SATA)

• A. Accompanied by shortness of breath
• B. Feelings of fear or anxiety
• C. Lasts longer than 15 minutes
• D. Relieved by taking nitroglycerin

Correct answer: A, C

Rationale: The pain of an MI is often accompanied by shortness of breath and feelings of fear or anxiety. It typically lasts longer than 15 minutes and is not relieved by nitroglycerin. Unlike stable angina, the pain of an MI occurs without a known cause such as exertion.

4. Prior to performing percussion, vibration, and postural drainage on an adolescent client with pneumonia, which of the following nursing actions should the nurse complete first?

• A. Auscultate lung fields
• B. Assess pulse and respirations
• C. Assess characteristics of the sputum
• D. Instruct the client to slowly exhale with pursed lips

Correct answer: Auscultate lung fields

Rationale: Before initiating percussion, vibration, and postural drainage, the nurse should first auscultate the lung fields to assess the baseline lung sounds and identify areas of congestion or abnormality. This initial assessment helps the nurse to tailor the percussion and drainage techniques effectively. Assessing pulse and respirations, sputum characteristics, and providing instructions to the client for exhalation are important steps in the procedure but should follow the initial auscultation to ensure a comprehensive and individualized care approach.

5. A client with a pleural effusion is being assessed by a nurse. Which clinical manifestation does the nurse expect to find?

• A. Decreased breath sounds on the affected side
• B. Hyperresonance on percussion of the affected side
• C. Increased tactile fremitus on the affected side
• D. Tracheal deviation toward the affected side

Correct answer: A

Rationale: In a client with pleural effusion, decreased breath sounds on the affected side are common due to the presence of fluid in the pleural space. Hyperresonance is not expected; dullness on percussion is more likely. Tactile fremitus is typically decreased, not increased, in pleural effusion cases. Tracheal deviation away from the affected side, not toward it, can be seen with large effusions.

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