Nursing Elites

1. A patient with bacterial pneumonia has rhonchi and thick sputum. What is the nurse's most appropriate action to promote airway clearance?

• A. Assist the patient to splint the chest when coughing.
• B. Teach the patient about the need for fluid intake.
• C. Encourage the patient to wear the nasal oxygen cannula.
• D. Instruct the patient on the pursed lip breathing technique.

Correct answer: A

Rationale: Assisting the patient to splint the chest when coughing is the most appropriate action to promote airway clearance in a patient with bacterial pneumonia, rhonchi, and thick sputum. Splinting the chest helps reduce pain during coughing and increases the effectiveness of clearing secretions. Teaching the patient about the need for fluid intake is important as it helps liquefy secretions, aiding in easier clearance. Encouraging the patient to wear a nasal oxygen cannula may improve gas exchange but does not directly promote airway clearance. Instructing the patient on the pursed lip breathing technique is beneficial for improving gas exchange in patients with COPD but does not directly aid in airway clearance in a patient with bacterial pneumonia and thick sputum.

2. A 23-year-old has been admitted with acute liver failure. Which assessment data are most important for the nurse to communicate to the healthcare provider?

• A. Asterixis and lethargy
• B. Jaundiced sclera and skin
• C. Elevated total bilirubin level
• D. Liver 3 cm below costal margin

Correct answer: A

Rationale: The most critical assessment data for the nurse to communicate to the healthcare provider in a patient with acute liver failure are asterixis and lethargy. These findings are indicative of grade 2 hepatic encephalopathy, which signals a rapid deterioration in the patient's condition, necessitating early transfer to a transplant center. Jaundiced sclera and skin, elevated total bilirubin level, and a liver 3 cm below the costal margin are all typical findings in hepatic failure but do not indicate an immediate need for a change in the therapeutic plan. Therefore, while these findings are relevant and should be reported, they are not as urgent as asterixis and lethargy in a patient with acute liver failure.

3. A systolic blood pressure of 145 mm Hg is classified as:

• A. Normotensive
• B. Prehypertension
• C. Stage I hypertension
• D. Stage II hypertension

Correct answer: C

Rationale: A systolic blood pressure of 145 mm Hg falls within the range of 140-159 mm Hg, which is classified as Stage I hypertension. Normotensive individuals have a systolic blood pressure less than 120 mm Hg, making choice A incorrect. Prehypertension is characterized by a systolic blood pressure ranging from 120-139 mm Hg, excluding choice B. Stage II hypertension is diagnosed when the systolic blood pressure is greater than 160 mm Hg, making choice D incorrect. Therefore, the correct classification for a systolic blood pressure of 145 mm Hg is Stage I hypertension.

4. 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.

5. The healthcare professional in the Emergency Room is treating a patient suspected to have a Peptic Ulcer. On assessing lab results, the healthcare professional finds that the patient's blood pressure is 95/60, pulse is 110 beats per minute, and the patient reports epigastric pain. What is the PRIORITY intervention?

• A. Start a large-bore IV in the patient's arm
• B. Ask the patient for a stool sample
• C. Prepare to insert an NG Tube
• D. Administer intramuscular morphine sulfate as ordered

Correct answer: A

Rationale: The priority intervention in this scenario is to start a large-bore IV in the patient's arm. The patient's low blood pressure (95/60) and elevated pulse rate (110 beats per minute) indicate a potential hemorrhage, requiring immediate fluid resuscitation. Starting a large-bore IV will allow for rapid administration of fluids to stabilize the patient's condition. Asking for a stool sample, preparing to insert an NG tube, or administering morphine sulfate should not take precedence over addressing the hemodynamic instability and potential hemorrhage observed in the patient. These actions may be considered later in the patient's care, but the primary focus should be on addressing the critical issue of fluid replacement and stabilization.

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