Nursing Elites

1. The nurse is assessing the thorax and lungs of a client who is experiencing respiratory difficulty. Which finding is most indicative of respiratory distress?

• A. Contractions of the sternocleidomastoid muscle.
• B. Respiratory rate of 20 breaths/min
• C. Downward movement of diaphragm with inspiration
• D. A pulse oximetry reading of SpO2 95%

Correct answer: A

Rationale: The correct answer is A: Contractions of the sternocleidomastoid muscle. Contractions of the sternocleidomastoid muscle suggest that the client is using accessory muscles to breathe, which is a clear sign of respiratory distress. This finding indicates that the client is working harder to breathe, typically seen in conditions like asthma, COPD, or respiratory failure. Choices B, C, and D are not the most indicative of respiratory distress. A respiratory rate of 20 breaths/min falls within the normal range. Downward movement of the diaphragm with inspiration is a normal finding indicating effective diaphragmatic breathing. A pulse oximetry reading of SpO2 95% is within the normal range and does not necessarily indicate respiratory distress.

2. A client with a history of atrial fibrillation is prescribed warfarin (Coumadin). Which clinical finding is most concerning?

• A. Headache
• B. Prothrombin time (PT) of 15 seconds
• C. Elevated liver enzymes
• D. Peripheral edema

Correct answer: A

Rationale: The correct answer is A: Headache. In a client with atrial fibrillation taking warfarin (Coumadin), a headache can be indicative of bleeding, which is a serious complication requiring immediate assessment and intervention. Monitoring for signs of bleeding is crucial when on anticoagulant therapy. Choices B, C, and D are not the most concerning. A prothrombin time of 15 seconds is within the therapeutic range for a client on warfarin, elevated liver enzymes may indicate liver dysfunction but are not directly related to the medication's side effects, and peripheral edema is not typically associated with warfarin use or atrial fibrillation in this context.

3. A female client with major depressive disorder tells the nurse she feels worthless and can't see how her life will ever get better. What is the best response by the nurse?

• A. I can understand how you feel. Tell me more about what's been going on.
• B. You're going through a tough time. Let's discuss what makes you feel this way.
• C. You sound very hopeless right now. Are you thinking about harming yourself?
• D. It's difficult to see the light when you're feeling this way, but I'm here to help you.

Correct answer: C

Rationale: Choice C is the best response because it directly addresses the client's expressed hopelessness and assesses the risk for self-harm. When a client with major depressive disorder expresses feeling worthless and unable to see improvement, it is essential to assess suicidal ideation to ensure their safety. Choices A, B, and D provide empathy and support, which are important but addressing suicidal ideation is the priority in this situation.

4. Which assessment finding requires immediate intervention for a client receiving enteral feedings via a nasogastric tube?

• A. Auscultate the client's lungs for breath sounds
• B. Check the client's blood glucose level
• C. Monitor the client's bowel sounds
• D. Elevate the head of the bed to 45 degrees

Correct answer: D

Rationale: Elevating the head of the bed to 45 degrees is crucial for clients receiving enteral feedings via a nasogastric tube to prevent aspiration. Aspiration can lead to serious complications such as pneumonia. Auscultating the client's lungs for breath sounds (choice A) is important but not as urgent as preventing aspiration. Checking the client's blood glucose level (choice B) and monitoring bowel sounds (choice C) are also essential aspects of care for a client receiving enteral feedings, but they do not take precedence over preventing aspiration.

5. To reduce staff nurse role ambiguity, which strategy should the nurse-manager implement?

• A. Review the staff nurse job description to ensure that it is clear, accurate, and current.
• B. Conduct regular meetings to clarify roles.
• C. Increase communication between team members.
• D. Provide additional training for new nurses.

Correct answer: A

Rationale: The correct answer is A: Review the staff nurse job description to ensure that it is clear, accurate, and current. By ensuring that job descriptions are clear and up-to-date, nurse-managers can reduce ambiguity and confusion about roles and responsibilities. Choice B, conducting regular meetings to clarify roles, may help but may not address the root cause of ambiguity. Choice C, increasing communication between team members, is important but may not specifically target role ambiguity. Choice D, providing additional training for new nurses, is valuable but may not directly address role ambiguity among existing staff.

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