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 healthcare professional is caring for a client who has a prescription for a stool specimen to be sent to the laboratory to be tested for ova and parasites. Which of the following instructions regarding specimen collection should the healthcare professional provide to the assistive personnel?

• A. Collect at least 2 inches of formed stool.
• B. Wear sterile gloves while obtaining the specimen.
• C. Use a culturette for specimen collection.
• D. Record the date and time the stool was collected.

Correct answer: A

Rationale: To ensure accurate testing, a minimum amount of stool is required for specimen collection, typically at least 2 inches of formed stool. This amount provides an adequate sample for testing. Wearing sterile gloves is important for infection control but is not specifically required for stool specimen collection. Using a culturette is not typically necessary for collecting stool specimens. Recording the date and time the stool was collected is essential to ensure timely processing but does not directly impact the collection of the specimen itself.

3. A client is experiencing dehydration, and the nurse is planning care. Which of the following actions should the nurse include?

• A. Administer antihypertensives as prescribed.
• B. Check the client’s weight daily.
• C. Notify the provider if the urine output is less than 30 mL/hr.
• D. Encourage the client to ambulate independently four times a day.

Correct answer: B

Rationale: Checking the client's weight daily is essential for monitoring fluid status in dehydration. Administering antihypertensives, notifying the provider of insufficient urine output, and encouraging ambulation are not primary interventions for managing dehydration. Administering antihypertensives may affect blood pressure, but it is not a direct intervention for dehydration. Notifying the provider of a urine output less than 30 mL/hr indicates oliguria, which is a sign of reduced kidney function rather than dehydration. Encouraging ambulation is a general nursing intervention and does not directly address the fluid imbalance associated with dehydration.

4. A nurse is caring for a client who has terminal lung cancer. The nurse observes the client’s family assisting with all ADLs. Which of the following rationales for self-care should the nurse communicate to the family?

• A. Allowing the client to function independently will strengthen muscles and promote healing.
• B. The client needs privacy at times for self-reflection and organizing life.
• C. The client’s sense of loss can be lessened through retaining control of some areas of life.
• D. Performing ADLs is a requirement prior to discharge from an acute care facility.

Correct answer: C

Rationale: The correct answer is C. In situations like terminal illness, allowing clients to perform activities of daily living (ADLs) can help maintain their sense of control and dignity, providing comfort and a sense of normalcy amidst their health challenges. Choice A is incorrect because in a terminal stage, the focus is not on muscle strength or promoting physical healing but rather on enhancing the client's emotional well-being. Choice B, while highlighting the importance of privacy, is not directly addressing the client's need for control and autonomy. Choice D is incorrect as the priority in this scenario is not related to discharge requirements but rather the client's emotional and psychological needs during their terminal illness.

5. A client admitted with abdominal pain tells the nurse that her father died recently, and she begins crying while talking about him. The nurse determines that the client’s temperature is 39.2°C (102.6°F), her abdomen is soft without tenderness, and her menses are overdue by 2 days. To which observation should the nurse give priority attention?

• A. The client’s temperature
• B. The client’s menses are overdue
• C. The client’s crying
• D. The client’s soft abdomen

Correct answer: B

Rationale: The correct answer is B. An overdue menses might indicate a potential cause of abdominal pain, especially in the context of recent emotional stress. While the client's temperature, crying, and soft abdomen are important observations, the priority should be given to the overdue menses as it could provide crucial information related to the abdominal pain and the client's overall health status. The emotional distress may have a secondary impact on the physical symptoms, making the menstrual status a critical observation to address first.

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