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 is being cared for by a nurse 2 hours after admission. The client has an SaO2 of 91%, exhibits audible wheezes, and is using accessory muscles when breathing. Which of the following classes of medication should the nurse expect to administer?

• A. Antibiotic
• B. Beta-blocker
• C. Antiviral
• D. Beta2 agonist

Correct answer: D

Rationale: The client's presentation with an SaO2 of 91%, audible wheezes, and use of accessory muscles indicates respiratory distress, likely due to bronchoconstriction. Beta2 agonists are the appropriate class of medications to administer in this situation as they act as bronchodilators, helping to relieve the bronchoconstriction and improve airflow to the lungs. Antibiotics, beta-blockers, and antivirals are not indicated for this client's respiratory distress symptoms.

3. For administering a cleansing enema, what is the common position typically used?

• A. Sims left lateral
• B. Dorsal Recumbent
• C. Supine
• D. Prone

Correct answer: A

Rationale: The correct position for administering a cleansing enema is the Sims left lateral position. This position is preferred as it helps to facilitate the procedure by allowing gravity to assist in the flow of the enema solution. The individual lies on their left side with the right knee flexed towards the chest, which helps to promote retention of the enema solution and its distribution throughout the colon. Choices B, C, and D are incorrect. The dorsal recumbent position (Choice B) is commonly used for physical examinations of the abdomen and genitalia. The supine position (Choice C) involves lying flat on the back and is not ideal for administering enemas. The prone position (Choice D) is lying flat on the stomach and is not suitable for administering enemas.

4. During a shift change, a nurse is receiving a report for an adult female client who is postoperative. Which of the following client information should the nurse report?

• A. High platelets
• B. Hypertension
• C. Lower platelets
• D. High temperatures

Correct answer: C

Rationale: Lower platelets can indicate a potential risk of bleeding in a postoperative client. Thrombocytopenia, or low platelet count, can lead to increased bleeding tendencies and should be promptly reported to the healthcare team for appropriate management. Monitoring platelet levels is crucial in postoperative care to prevent complications related to inadequate clotting ability.

5. During a Romberg test, the patient is asked to assume which position?

• A. Sitting
• B. Standing
• C. Genupectoral
• D. Trendelenburg

Correct answer: B

Rationale: During a Romberg test, the patient is asked to stand with feet together and arms at the sides. The test evaluates proprioception and vestibular function by assessing the patient's ability to maintain balance with eyes closed. Asking the patient to stand helps to detect any balance issues or disturbances in the absence of visual input.

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