Nursing Elites

1. Which of the following goals is the most important for the nurse to address for a client admitted to the cardiac rehabilitation unit?

• A. Reduction of anxiety
• B. Referral to community resources
• C. Identification of lifestyle changes
• D. Verbalization of energy-conservation techniques

Correct answer: C

Rationale: The most important goal for a client admitted to the cardiac rehabilitation unit is the identification of lifestyle changes. This is crucial in promoting cardiovascular health and preventing future cardiac issues. Lifestyle changes such as diet modifications, exercise routines, smoking cessation, and stress management play a significant role in improving the overall cardiovascular well-being of the patient. While reducing anxiety, referring to community resources, and verbalizing energy-conservation techniques are all important aspects of care, identifying lifestyle changes is the primary focus in helping the client achieve long-term cardiovascular wellness.

2. When discussing the child's wishes for future care, it is important for the nurse to first identify what the child knows about the disease and his prognosis. Factors such as the perceived severity of the illness will be significant in planning for end-of-life care. If the child does not understand the disease process or prognosis, the plan of care would not be effective or realistic. In addition, asking a child about desired interventions in the event of cardiac or respiratory arrest would not be an appropriate initial area of questioning. If the child does not understand the disease process, these questions may seem frightening or threatening. While exploring the child's belief about death would be important, it would not be the initial area of discussion and should be guided by the child rather than the nurse.

• A. What the child knows about the disease and his prognosis.
• B. How the child would like to handle the plan of care.
• C. What interventions the child would like in the event of cardiac or respiratory arrest.
• D. What the child believes about death.

Correct answer: A

Rationale: When discussing the child's wishes for future care, it is essential to first determine what the child understands about the disease and his prognosis. This information is crucial for planning appropriate end-of-life care. If the child lacks comprehension of the illness and its prognosis, any care plan discussed would be ineffective and unrealistic. Inquiring about desired interventions during cardiac or respiratory arrest is not the initial step, as it may cause distress if the child lacks understanding. While exploring the child's beliefs about death is significant, it should not be the primary focus initially and should be approached based on the child's readiness, not the nurse's agenda. Therefore, the correct first step is to assess what the child knows about the disease and his prognosis.

3. A client returns to the nursing unit post-thoracotomy with two chest tubes in place connected to a drainage device. The client's spouse asks the nurse about the reason for having two chest tubes. The nurse's response is based on the knowledge that the upper chest tube is placed to:

• A. Remove air from the pleural space
• B. Create access for irrigating the chest cavity
• C. Evacuate secretions from the bronchioles and alveoli
• D. Drain blood and fluid from the pleural space

Correct answer: A

Rationale: The correct answer is 'Remove air from the pleural space.' When a client has two chest tubes in place post-thoracotomy, the upper chest tube is typically positioned to remove air from the pleural space. Air rises, so placing the tube at the top allows for efficient removal of air that has accumulated in the pleural cavity. Choice B, creating access for irrigating the chest cavity, is incorrect as chest tubes are not primarily used for irrigation. Choice C, evacuating secretions from the bronchioles and alveoli, is incorrect as chest tubes are not designed for this purpose. Choice D, draining blood and fluid from the pleural space, is also incorrect as the upper chest tube in this scenario is specifically for removing air, not blood or fluid.

4. Which of the following can certain foods like broccoli, oranges, dark greens, and dark yellow vegetables help improve?

• A. Vitamin intake
• B. Body functions
• C. Defense mechanisms
• D. Disease cure

Correct answer: C

Rationale: Certain foods like broccoli, oranges, dark greens, and dark yellow vegetables can help improve defense mechanisms by enhancing the immune system and overall health. While these foods can boost defense mechanisms, they are not a cure for diseases, do not balance body functions, and are not intended to solely supplement vitamin intake, which may be necessary in some cases. Therefore, the correct answer is defense mechanisms as these foods strengthen the body's ability to fight off illnesses and maintain health.

5. What do the following ABG values indicate: pH 7.38, PO2 78 mmHg, PCO2 36mmHg, and HCO3 24 mEq/L?

• A. metabolic alkalosis
• B. homeostasis
• C. respiratory acidosis
• D. respiratory alkalosis

Correct answer: B

Rationale: The correct answer is 'homeostasis.' These ABG values fall within normal ranges, indicating a state of balance in the body's acid-base levels. Choices A, C, and D are incorrect as the ABG values provided do not point towards metabolic alkalosis, respiratory acidosis, or respiratory alkalosis. Instead, the values reflect a state of equilibrium where pH, PO2, PCO2, and HCO3 levels are within the normal range.

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