Nursing Elites

1. The charge nurse on a cardiac unit tells you a patient is exhibiting signs of right-sided heart failure. Which of the following would not indicate right-sided heart failure?

• A. Muscle tetany
• B. Syncope
• C. Numbness
• D. Anxiety

Correct answer: D

Rationale: The correct answer is 'Anxiety.' Anxiety is not a typical sign of right-sided heart failure. Right-sided heart failure usually presents with symptoms such as muscle tetany, syncope, and numbness. Muscle tetany can occur due to electrolyte imbalances seen in heart failure. Syncope can result from decreased cardiac output, leading to decreased perfusion to the brain. Numbness can occur due to poor circulation. While anxiety can be present in patients with various medical conditions, it is more commonly associated with respiratory acidosis or other psychological factors rather than right-sided heart failure.

2. Which of the following is likely to increase the risk of sexually transmitted disease?

• A. alcohol use
• B. certain types of sexual practices
• C. oral contraception use
• D. all of the above

Correct answer: D

Rationale: All of the above factors are likely to increase the risk of sexually transmitted diseases (STDs). Alcohol use can impair judgment, leading to risky sexual behavior. Certain types of sexual practices, especially unprotected sex or multiple partners, increase the likelihood of contracting STDs. While oral contraception use does not directly increase the risk of STDs, it does not protect against them either. Therefore, all the choices (alcohol use, certain types of sexual practices, and oral contraception use) can contribute to an increased risk of contracting STDs.

3. A client delivered a term male infant four hours ago. The infant was stillborn. Which room assignment would be most appropriate for this client?

• A. Request a private room on the GYN floor
• B. Assign her to a private room on the postpartum unit
• C. Discharge her home as soon as her condition is stable
• D. Room her with another client who experienced a pregnancy loss

Correct answer: A

Rationale: In this situation, the most appropriate room assignment for the client who delivered a stillborn infant would be to request a private room on the GYN floor. This client needs privacy to grieve, and having a private space allows for family members to offer support. Placing her in a GYN unit ensures that she is away from the maternity unit's sights and sounds, which could be painful reminders for her. Assigning her to a postpartum unit may cause distress due to the presence of other mothers and newborns. Discharging her home too early may not allow her sufficient time for emotional and physical recovery. Rooming her with another client who experienced a pregnancy loss may not provide the necessary privacy and space she needs for her emotional well-being.

4. A 64-year-old Alzheimer's patient has exhibited excessive cognitive decline resulting in harmful behaviors. The physician orders restraints to be placed on the patient. Which of the following is the appropriate procedure?

• A. Secure the restraints to the bed rails on all extremities.
• B. Notify the physician that restraints have been placed properly.
• C. Communicate with the patient and family the need for restraints.
• D. Position the head of the bed at a 45-degree angle.

Correct answer: C

Rationale: In cases where restraints are considered necessary for a patient, it is crucial to communicate effectively with both the patient and their family about the reasons for this decision. This helps ensure that all parties involved understand the necessity of restraints and are informed about the potential risks and benefits. Option A, securing restraints to the bed rails on all extremities, is not appropriate as it does not involve proper communication or ethical considerations. Option B, notifying the physician that restraints have been placed properly, overlooks the importance of patient and family involvement in decision-making. Option D, positioning the head of the bed at a 45-degree angle, is unrelated to the use of restraints and does not address the situation at hand.

5. The nurse is assessing the newborn's respirations. Which of these findings would indicate a need for follow-up and further intervention?

• A. irregular respirations
• B. abdominal respirations
• C. shallow respirations
• D. 70 breaths per minute

Correct answer: D

Rationale: The ideal respiratory rate in a newborn is 30-60 breaths per minute. A respiratory rate of 70 breaths per minute indicates tachypnea and may require intervention. Therefore, a rate of 70 breaths per minute would necessitate follow-up and further intervention. Irregular, abdominal, and shallow respirations are common in newborns and may not necessarily indicate the need for immediate follow-up or intervention.

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