Nursing Elites

1. The PN is assisting the recreational director of a long-term care facility to plan outdoor activities for wheelchair-bound older residents who are mentally alert. Which activity meets the physical and social needs of these residents?

• A. An open-air concert
• B. A tea party in the courtyard
• C. A team ring-toss competition
• D. A picnic in the park

Correct answer: B

Rationale: A tea party in the courtyard is the most suitable activity as it allows for social interaction in a comfortable and accessible environment. Wheelchair-bound residents can easily participate, fostering both physical and social engagement. An open-air concert may pose challenges regarding accessibility and comfort for wheelchair-bound individuals. A team ring-toss competition involves physical activity that may not be inclusive for all residents, especially those in wheelchairs. A picnic in the park may also present challenges related to accessibility and comfort for wheelchair-bound individuals.

2. A client post-thoracotomy is complaining of severe pain with deep breathing and coughing. What should the nurse encourage the client to do to manage the pain and prevent respiratory complications?

• A. Hold a pillow against the chest while coughing (splinting).
• B. Take shallow breaths to avoid pain.
• C. Increase the dose of pain medication.
• D. Avoid deep breathing exercises.

Correct answer: A

Rationale: Splinting the chest with a pillow helps manage pain during deep breathing and coughing, which is essential to prevent respiratory complications such as atelectasis or pneumonia after thoracic surgery. Holding a pillow against the chest while coughing (splinting) supports the incision site and reduces the pain associated with deep breathing and coughing. Encouraging shallow breaths (Choice B) can lead to respiratory complications due to inadequate lung expansion. Increasing pain medication (Choice C) should be done based on healthcare provider orders and not solely for this situation. Avoiding deep breathing exercises (Choice D) can worsen respiratory function and increase the risk of complications.

3. When documenting information in a client's medical record, what should the nurse do?

• A. Cross out errors with a single line and initial them
• B. Use a black ink pen
• C. Leave one line blank before each new entry
• D. End each entry with the nurse's signature and title

Correct answer: D

Rationale: When documenting information in a client's medical record, the nurse should end each entry with their signature and title. This practice is crucial for legal and professional standards compliance as it ensures that the documentation is attributable to the responsible individual. Choices A, B, and C are incorrect because while crossing out errors, using a black ink pen, and leaving a blank line before each entry are good practices, they are not as critical as ensuring each entry is signed and titled by the nurse for accountability and traceability.

4. What is the priority intervention for a patient experiencing an acute asthma attack?

• A. Administering a bronchodilator
• B. Encouraging the patient to drink fluids
• C. Applying a high-flow oxygen mask
• D. Performing chest physiotherapy

Correct answer: A

Rationale: Administering a bronchodilator is the priority intervention in an acute asthma attack. Bronchodilators help to quickly open the airways, relieve bronchospasm, and improve breathing. Encouraging the patient to drink fluids may be beneficial for other conditions but is not the priority in an acute asthma attack. Applying a high-flow oxygen mask may be necessary in severe cases of respiratory distress but is not the initial priority when managing an acute asthma attack. Performing chest physiotherapy is not indicated as the primary intervention for an acute asthma attack and may not address the immediate need to open the airways and improve breathing.

5. A client who had an abdominal hysterectomy is experiencing minimal urine output despite adequate fluid intake. What should the nurse assess first?

• A. The client's bladder for distension.
• B. The IV catheter insertion site.
• C. The patency of the urinary catheter.
• D. The client's vital signs.

Correct answer: C

Rationale: Assessing the patency of the urinary catheter is crucial in this situation. A blocked catheter could be a common cause of decreased urine output following surgery. While checking the IV catheter insertion site (Choice B) is important, it is not the priority in this case. Examining the client's bladder for distension (Choice A) is relevant, but assessing the patency of the catheter takes precedence in resolving the issue of decreased urine output. Monitoring vital signs (Choice D) is a routine nursing task but not the priority when dealing with decreased urine output post-surgery.

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