Nursing Elites

1. An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be taken by the nurse is to:

• A. Check the carotid pulse
• B. Deliver 5 abdominal thrusts
• C. Give 2 rescue breaths
• D. Open the client's airway

Correct answer: D

Rationale: In this scenario, the priority is to ensure the client has a clear airway to facilitate breathing. After verifying unresponsiveness and calling for help, the nurse should open the client's airway to aid in maintaining ventilation. Checking the carotid pulse (Choice A) may be important but comes after ensuring a clear airway. Delivering abdominal thrusts (Choice B) is indicated for choking, not for an unresponsive client. Giving rescue breaths (Choice C) is also important but only after the airway has been established.

2. A client in the terminal stage of cancer is crying. What action should the nurse take?

• A. Sit and hold the client's hand
• B. Encourage the client to talk about their feelings
• C. Leave the client alone to cry
• D. Ignore the client's crying

Correct answer: A

Rationale: In situations where a client is in the terminal stage of cancer and crying, it is essential for the nurse to provide comfort and support. Sitting with the client and holding their hand can offer a sense of presence and emotional support, showing empathy and understanding. Encouraging the client to talk about their feelings (choice B) is also important, but initially, non-verbal support through physical presence can be comforting. Leaving the client alone to cry (choice C) can make the client feel abandoned and unsupported during a vulnerable moment. Ignoring the client's crying (choice D) is not appropriate and lacks compassion and empathy, which are crucial in end-of-life care.

3. The patient is immobilized after undergoing hip replacement surgery. Which finding will alert the nurse to monitor for hemorrhage in this patient?

• A. Thick, tenacious pulmonary secretions
• B. Low-molecular-weight heparin doses
• C. SCDs wrapped around the legs
• D. Elastic stockings (TED hose)

Correct answer: B

Rationale: The correct answer is B, which is low-molecular-weight heparin doses. After hip replacement surgery, patients are at risk of developing deep vein thrombosis (DVT) due to immobility. Heparin and low-molecular-weight heparin are commonly used for prophylaxis against DVT. Monitoring for hemorrhage is crucial when administering anticoagulants. Choices A, C, and D are not directly related to monitoring for hemorrhage in this scenario. Thick, tenacious pulmonary secretions (Choice A) may indicate respiratory issues, SCDs (Choice C) help prevent DVT but do not directly relate to hemorrhage monitoring, and elastic stockings (TED hose) (Choice D) are used for DVT prophylaxis but do not alert to hemorrhage.

4. A healthcare provider is providing discharge teaching to a client about self-administering heparin.

• A. Administer medication in the abdomen.
• B. Administer medication in the thigh.
• C. Administer medication in the upper arm.
• D. Administer medication in the buttock.

Correct answer: A

Rationale: Heparin is typically administered in the abdomen for self-injection to avoid muscle tissue and for better absorption. The subcutaneous tissue in the abdomen provides a larger area for injection and is usually recommended for heparin administration. Administering heparin in the thigh, upper arm, or buttock may not be as effective or safe as the abdomen due to variations in absorption rates and potential risks associated with muscle injection.

5. A healthcare provider in an office is preparing to auscultate and percuss a client’s thorax as part of a comprehensive physical examination. Which of the following findings should the provider expect?

• A. Rhonchi
• B. Crackles
• C. Resonance
• D. Tactile fremitus

Correct answer: C

Rationale: During a thoracic examination, normal findings should include resonance, which is the expected sound when percussing the thorax. Resonance indicates healthy lung tissue and air-filled spaces. Abnormal findings such as rhonchi and crackles suggest issues like lung congestion or inflammation. Tactile fremitus refers to vibrations felt on the chest wall during palpation and is not typically assessed during percussion and auscultation of the thorax.

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