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. A client has global aphasia affecting both receptive and expressive language abilities. Which intervention should NOT be included in the client's care plan?

• A. Speak to the client at a slower rate.
• B. Assist the client in using flash cards with pictures.
• C. Speak to the client in a loud voice.
• D. Give instructions one step at a time.

Correct answer: C

Rationale: Individuals with global aphasia have difficulty understanding and expressing language. Speaking loudly may not improve comprehension and can be perceived as aggressive. Therefore, it is important not to speak loudly to a client with global aphasia. Speaking at a slower rate, using visual aids like flash cards, and breaking down instructions into simple steps can facilitate communication and understanding for the client.

3. A healthcare provider reaches to answer the telephone on a busy pediatric unit, momentarily turning away from a 3-month-old infant she has been weighing. The infant falls off the scale, suffering a skull fracture. The healthcare provider could be charged with:

• A. Defamation
• B. Assault
• C. Battery
• D. Malpractice

Correct answer: D

Rationale: The scenario described involves a breach of duty by the healthcare provider to properly supervise the infant, resulting in harm. This failure to meet the standard of care falls under the category of malpractice, which refers to professional negligence or misconduct. Malpractice specifically applies to situations where a healthcare provider's actions or omissions deviate from the accepted standard of care, causing harm to a patient. In this case, the nurse's lack of supervision leading to the infant falling off the scale and sustaining a skull fracture would be considered malpractice.

4. What is a muscular enlarged pouch or sac that lies slightly to the left and is used for the temporary storage of food?

• A. Gallbladder
• B. Urinary bladder
• C. Stomach
• D. Lungs

Correct answer: C

Rationale: The correct answer is the stomach. The stomach is a muscular organ located slightly to the left in the abdominal cavity. It serves as a temporary storage site for food where it is mixed with digestive enzymes and acids to begin the process of digestion. The gallbladder (Choice A) is not involved in food storage; it stores bile produced by the liver. The urinary bladder (Choice B) is part of the urinary system and stores urine. The lungs (Choice D) are responsible for respiration, not food storage.

5. In the emergency department, a nurse is assessing a client involved in a motor vehicle crash. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 38.6 C (101.4 F), and SaO2 92% on room air. What action should the nurse take first?

• A. Obtain a chest X-ray.
• B. Prepare for chest tube insertion.
• C. Administer oxygen via high-flow mask.
• D. Initiate IV access.

Correct answer: C

Rationale: In this scenario, the client is presenting with signs of respiratory distress, including absent breath sounds, dyspnea, and a low SaO2 level. The priority action should be to improve oxygenation by administering oxygen via a high-flow mask. This intervention aims to increase the oxygen supply to the client's lungs, helping to address the hypoxemia. Once oxygenation is optimized, further interventions, such as obtaining a chest X-ray, preparing for chest tube insertion, or initiating IV access, can be considered based on the client's condition and healthcare provider's orders.

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