Nursing Elites

1. Which desired outcome written by the nurse is correctly written and measurable?

• A. Client will have a normal bowel pattern by April 2
• B. The client will lose 4 lbs. within the next 2 weeks
• C. The nurse will provide skin care at least 3 times each day
• D. The client will breathe better after resting for 10 minutes

Correct answer: B

Rationale: An outcome statement must describe the observable client behavior that should occur in response to the nursing interventions. It consists of a subject, action verb, conditions under which the behavior is to be performed, and the level at which the client will perform the desired behavior. Option B is correctly written and measurable as it includes all the required elements: subject (client), action verb (lose), conditions (within the next 2 weeks), and the level at which the behavior should occur (4 lbs.). Option A lacks the conditions and a specific level, making it not measurable. Option C is a nursing intervention rather than a client goal. Option D does not provide a specific level at which the client should perform the desired behavior, making it not measurable as well.

2. When assessing the pulse of a 6-year-old patient, the nurse notices that the heart rate varies with the respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration. What action would the nurse take next?

• A. Notify the physician.
• B. Record this finding as normal.
• C. Check the child's blood pressure and note any variation with respiration.
• D. Document that this child has bradycardia and continue with the assessment.

Correct answer: B

Rationale: The correct action for the nurse to take next is to record this finding as normal. Sinus dysrhythmia, characterized by heart rate variation with the respiratory cycle, is commonly found in children and young adults. The heart rate speeds up at the peak of inspiration and slows to normal with expiration. This phenomenon is a normal variant and does not require any intervention. There is no need to notify the physician as this finding is within the expected range for this age group. Checking the child's blood pressure for variations with respiration or documenting the child as having bradycardia would not be appropriate in this case, as sinus dysrhythmia is a normal physiological response.

3. Should standard precautions be used when providing post mortem care to a patient who has died from a massive heart attack and had no other diseases, illnesses, or infections?

• A. Yes, because the patient must be treated with respect
• B. Yes, you still must use standard precautions
• C. No, because the patient had no infections
• D. No, because this is not respectful

Correct answer: B

Rationale: Yes, you must still use standard precautions when providing post mortem care, regardless of the patient's medical history. Standard precautions are essential to prevent the transmission of potential infectious agents and protect both the healthcare provider and others from exposure. Even if the patient did not have known infections, it is crucial to maintain a safe environment and uphold professional standards of care. Choice A is incorrect as using standard precautions is primarily for infection control rather than solely for respect. Choices C and D are incorrect as the absence of infections or the notion of respect does not negate the need for standard precautions in post mortem care.

4. Which of the following sets of word parts means 'Pain'?

• A. dynia and -algia
• B. a- and an
• C. ia and -ac
• D. pathy and -osis

Correct answer: A

Rationale: The correct answer is 'dynia and -algia.' The word parts 'dynia' and '-algia' specifically relate to pain. 'Dynia' refers to pain, and '-algia' also denotes pain. Therefore, when combined, they form the meaning 'pain.' Choices B, C, and D are incorrect because 'a-' and 'an' do not relate to pain, 'ia' and '-ac' do not specifically convey pain, and 'pathy' and '-osis' are not word parts that directly signify pain.

5. After receiving change-of-shift report, which patient should the nurse assess first?

• A. A patient with pneumonia who has crackles in the right lung base
• B. A patient with possible lung cancer who has just returned after bronchoscopy
• C. A patient with hemoptysis and a 16-mm induration with tuberculin skin testing
• D. A patient with chronic obstructive pulmonary disease (COPD) and pulmonary function testing (PFT) that indicates low forced vital capacity

Correct answer: B

Rationale: The correct answer is the patient with possible lung cancer who has just returned after bronchoscopy. After bronchoscopy, the patient may have decreased cough and gag reflexes, necessitating immediate assessment for airway patency to prevent potential complications. The other patients do not exhibit urgent clinical manifestations or have undergone recent procedures that require immediate attention. Therefore, they can be assessed after ensuring the safety and stability of the patient who has just returned after bronchoscopy.

Similar Questions