Nursing Elites

1. When initiating cardiopulmonary resuscitation (CPR), what assessment finding must the healthcare provider confirm before beginning chest compressions?

• A. Absence of a pulse
• B. Presence of a pulse
• C. Respiratory rate
• D. Blood pressure

Correct answer: A

Rationale: The correct answer is A: Absence of a pulse. Prior to initiating chest compressions during CPR, it is essential to confirm the absence of a pulse. Chest compressions are indicated when there is no detectable pulse as it signifies cardiac arrest. Checking for a pulse is a critical step to ensure that CPR is performed on individuals who truly require it. Choices B, C, and D are incorrect because focusing on the presence of a pulse, respiratory rate, or blood pressure before starting chest compressions can delay life-saving interventions in a person experiencing cardiac arrest.

2. A nurse on a medical-surgical unit has received change-of-shift report and will care for four clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)?

• A. Updating the plan of care for a client who is postoperative
• B. Reinforcing teaching with a client who is learning to walk using a quad cane
• C. Reapplying a condom catheter for a client who has urinary incontinence
• D. Applying a sterile dressing to a pressure injury

Correct answer: C

Rationale: The correct answer is C - 'Reapplying a condom catheter for a client who has urinary incontinence.' This task falls within the scope of duties for an assistive personnel (AP). Updating care plans (Choice A), reinforcing teaching (Choice B), and applying sterile dressings (Choice D) typically require a higher level of training and expertise, making them tasks that should not be assigned to an AP. Assigning appropriate tasks based on skill levels ensures safe and effective patient care.

3. A client with pneumonia is receiving antibiotic therapy. Which finding indicates that the treatment is effective?

• A. Decreased white blood cell count
• B. Decreased respiratory rate
• C. Increased breath sounds
• D. Increased heart rate

Correct answer: C

Rationale: The correct answer is C: Increased breath sounds. When a client with pneumonia is receiving antibiotic therapy, increased breath sounds indicate that the lungs are clearing and the pneumonia is resolving. This improvement in breath sounds suggests that the antibiotics are effectively treating the infection. Choices A, B, and D are incorrect because a decreased white blood cell count, decreased respiratory rate, and increased heart rate are not specific indicators of the effectiveness of antibiotic therapy in treating pneumonia. While these parameters may change in response to treatment, they do not directly reflect the resolution of the pneumonia infection.

4. A patient's hygiene schedule of bathing and brushing teeth is largely influenced by family customs. For which age group is the nurse most likely providing care?

• A. Adolescent
• B. Preschooler
• C. Older adult
• D. Adult

Correct answer: B

Rationale: The correct answer is B: Preschooler. Family customs have a significant impact on hygiene practices during childhood, especially in the early years. Preschoolers are at an age where they are learning and forming habits, and family customs play a crucial role in establishing routines such as bathing and brushing teeth. Adolescents, older adults, and adults are more likely to have established their own hygiene routines that may not be as heavily influenced by family customs as in early childhood. Therefore, the nurse is most likely providing care to a preschooler in this scenario.

5. The nurse is providing discharge teaching to a client who has been prescribed digoxin (Lanoxin). Which statement by the client indicates a need for further teaching?

• A. I should take my pulse before taking the medication.
• B. I will take my medication at the same time every day.
• C. I should avoid taking antacids at the same time as this medication.
• D. I should eat foods high in potassium while taking this medication.

Correct answer: D

Rationale: The correct answer is D. Eating foods high in potassium can lead to hyperkalemia when taken with digoxin, indicating a need for further teaching. Choices A, B, and C are all correct statements that demonstrate understanding of digoxin therapy. Taking the pulse, maintaining a consistent dosing schedule, and avoiding antacids to prevent interactions with digoxin are all appropriate client responses.

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