Nursing Elites

1. Mr. Y had surgery two days ago and is recovering on the surgical unit of the hospital. Just before lunch, he develops chest pain and difficulties with breathing. His respiratory rate is 32/minute, his temperature is 100.8�F, and he has rales on auscultation. Which of the following nursing interventions is most appropriate in this situation?

• A. Place the client in the Trendelenburg position
• B. Contact the physician for an order for antibiotics
• C. Administer oxygen therapy
• D. Decrease his IV rate

Correct answer: C

Rationale: Chest pain, dyspnea, tachypnea, mild fever, and rales or crackles on auscultation in a client who had surgery 2 days ago may be indicative of a pulmonary embolism. The nurse should administer oxygen to address his breathing and assist him to a comfortable position to facilitate better oxygenation before contacting the physician. Placing the client in the Trendelenburg position is not recommended in this situation as it may worsen a potential pulmonary embolism by increasing venous return. Contacting the physician for antibiotics is not the priority as the immediate concern is addressing the breathing difficulty. Decreasing the IV rate is not indicated in this situation where the client is experiencing respiratory distress and needs oxygen therapy.

2. Which of these devices is considered a protective device, rather than a restraint?

• A. A mitten on the hands to prevent scratching
• B. A mitten on the hands to prevent the person from pulling their IV out
• C. A side rail to prevent the patient from falling
• D. A soft wrist restraint to prevent the patient from pulling their IV tubing

Correct answer: A

Rationale: A mitten on the hands to prevent scratching is considered a protective device because its primary purpose is to protect the patient from harming themselves by scratching. It does not restrict the patient's movement. Choice B, a mitten on the hands to prevent the person from pulling their IV out, is considered a restraint as it limits the patient's movement. Choice C, a side rail to prevent the patient from falling, is also a protective device as it aims to keep the patient safe by providing support and preventing falls. Choice D, a soft wrist restraint to prevent the patient from pulling their IV tubing, is a type of restraint as it restricts the patient's movement to prevent them from interfering with medical equipment.

3. Which of the following screening tools have been found to have high diagnostic accuracy for screening for intimate partner violence?

• A. Hurt, Insult, Threaten, and Scream (HITS)
• B. Humiliation, Afraid, Rape, and Kick (HARK)
• C. Slapped, Threatened, and Thrown (STaT)
• D. All of the above

Correct answer: D

Rationale: All of the above screening tools, including HITS, HARK, and STaT, have been found to have high diagnostic accuracy for screening intimate partner violence, as per the National Preventive Services Task Force. These tools are effective in identifying current or recent intimate partner violence. While the Partner Violence screen may have some predictive value for future intimate partner violence, the question specifically focuses on screening tools with high diagnostic accuracy, making 'All of the above' the correct choice. Choices A, B, and C are specific validated screening tools for intimate partner violence, each with its own set of questions that have been shown to be effective in identifying individuals experiencing intimate partner violence. Therefore, 'All of the above' is the most comprehensive and accurate choice for this question.

4. A client with a new prescription for lithium carbonate for bipolar disorder is being educated by a nurse on early indications of toxicity. The nurse should include which of the following manifestations in the teachings?

• A. Constipation
• B. Polyuria
• C. Rash
• D. Tinnitus

Correct answer: B

Rationale: Polyuria is a crucial early indication of lithium toxicity. It results from the drug's effect on the kidneys, leading to increased urine output. This is a significant symptom to monitor as it can indicate potential toxicity. Constipation, rash, and tinnitus are not typically associated with early indications of lithium toxicity. Constipation is more commonly seen as a side effect of some medications, while rash and tinnitus are not specific indicators of lithium toxicity.

5. Which of the following conditions may cause an increased respiratory rate?

• A. Stooped posture
• B. Narcotic analgesics
• C. Injury to the brain stem
• D. Anemia

Correct answer: D

Rationale: Anemia can lead to an increased respiratory rate. In anemia, there are decreased levels of hemoglobin in red blood cells, which are responsible for carrying oxygen to the body's tissues. To compensate for the reduced oxygen-carrying capacity, the body increases the respiratory rate to bring in more oxygen. Stooped posture (Choice A) is not directly related to an increased respiratory rate. Narcotic analgesics (Choice B) are more likely to cause a decreased respiratory rate due to their central nervous system depressant effects. Injury to the brain stem (Choice C) can affect respiratory function but may not necessarily lead to an increased respiratory rate.

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