Nursing Elites

1. Which of the following signs and symptoms would the nurse expect to find when assessing an Asian patient for postoperative pain following abdominal surgery?

• A. Decreased blood pressure and heart rate and shallow respirations
• B. Quiet crying
• C. Immobility, diaphoresis, and avoidance of deep breathing or coughing
• D. Changing position every 2 hours

Correct answer: C

Rationale: Immobility, diaphoresis, and avoidance of deep breathing or coughing are common signs of pain.

2. What is the best position for examining the rectum?

• A. Prone
• B. Sim's
• C. Knee-chest
• D. Lithotomy

Correct answer: C

Rationale: The knee-chest position is the most optimal position for examining the rectum. In this position, the patient kneels on the examination table with their chest resting on it, creating a straight line from the head to the lower back. This position allows for easier access and visualization of the rectal area, making it the preferred choice for rectal examinations. Prone position (choice A) is lying face down and is not ideal for rectal exams as it does not provide good access. Sim's position (choice B) is lying on the left side with the right knee and thigh flexed, also not ideal for rectal exams. Lithotomy position (choice D) is lying on the back with legs flexed and feet in stirrups, primarily used for gynecological exams and surgery, not for rectal examinations.

3. A client who is at 38 weeks gestation, is in active labor, and has ruptured membranes is being cared for by a nurse. What action should the nurse take?

• A. Insert an indwelling urinary catheter
• B. Apply fetal heart rate monitor
• C. Initiate fundal massage
• D. Initiate an oxytocin IV infusion

Correct answer: B

Rationale: When caring for a client in active labor with ruptured membranes, the priority action for the nurse is to apply a fetal heart rate monitor. This helps monitor the well-being of the fetus during labor and delivery, enabling timely interventions if any fetal distress is detected. Inserting an indwelling urinary catheter may be required in some cases, but it is not the priority in the given scenario. Fundal massage is typically done after delivery to help the uterus contract and prevent postpartum hemorrhage. Initiating an oxytocin IV infusion may be indicated to augment labor, but it is not the initial action needed in this situation.

4. When planning care for a client with severe acute respiratory distress syndrome (SARS), which of the following actions should not be included in the care plan?

• A. Administer antibiotics
• B. Provide supplemental oxygen
• C. Administer antiviral medications
• D. Administer bronchodilators

Correct answer: A

Rationale: Severe acute respiratory distress syndrome (SARS) is caused by a virus, not bacteria, and antibiotics are ineffective against viral infections. Therefore, administering antibiotics would not be appropriate in the care plan for a client with SARS. The priority interventions for SARS include providing supplemental oxygen to improve oxygenation, administering antiviral medications to target the viral infection, and using bronchodilators to help with bronchospasm or airway constriction. Antibiotics are not indicated unless there is a secondary bacterial infection present.

5. Which of the following interventions promotes patient safety?

• A. Assess the patient’s ability to ambulate and transfer from a bed to a chair
• B. Demonstrate the signal system to the patient
• C. Check to see that the patient is wearing their identification band
• D. All of the above

Correct answer: D

Rationale: All the listed interventions are essential for promoting patient safety. Assessing the patient’s ability to ambulate and transfer helps prevent falls, demonstrating the signal system ensures effective communication in emergencies, and checking the patient's identification band aids in accurate identification and treatment. By combining these interventions, healthcare providers can enhance patient safety and quality of care.

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