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 receiving vecuronium for acute respiratory distress syndrome. Which of the following medications should the nurse anticipate administering with this medication?

• A. Fentanyl
• B. Furosemide
• C. Famotidine
• D. Dexamethasone

Correct answer: A

Rationale: Vecuronium is a neuromuscular blocking agent used for muscle relaxation during mechanical ventilation. When administering vecuronium, it is common to also give an opioid analgesic, such as fentanyl, to manage pain and ensure the patient's comfort. Fentanyl is often used in combination with neuromuscular blocking agents to provide balanced anesthesia, making it the appropriate medication to anticipate administering in this scenario.

3. A client experiencing dyspnea will receive continuous oxygen. Which oxygen device should be used to deliver a precise amount of oxygen?

• A. Non-rebreather mask
• B. Venturi mask
• C. Nasal cannula
• D. Simple face mask

Correct answer: B

Rationale: A Venturi mask is the most appropriate choice for delivering a precise amount of oxygen to a client with dyspnea. Unlike other oxygen delivery devices, the Venturi mask allows for accurate oxygen concentration delivery by controlling the amount of air entrained. This feature is crucial in ensuring the client receives the prescribed oxygen concentration, especially in cases where precise oxygen delivery is required.

4. The physician orders the administration of high-humidity oxygen by face mask and placement of the patient in a high Fowler’s position. After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. Which of the following nursing interventions has the greatest potential for improving this situation?

• A. Encourage the patient to increase her fluid intake to 200 ml every 2 hours
• B. Place a humidifier in the patient’s room
• C. Continue administering oxygen by high humidity face mask
• D. Perform chest physiotherapy on a regular schedule

Correct answer: D

Rationale: Chest physiotherapy is the most effective intervention in cases of impaired gas exchange related to increased secretions. This technique helps mobilize and clear secretions from the airways, thereby improving gas exchange in the lungs. Placing a humidifier or administering oxygen by high humidity face mask may provide moisture but may not directly address the clearance of secretions. Encouraging increased fluid intake can help with hydration but may not address the underlying issue of impaired gas exchange due to secretions.

5. Which of the following statements is incorrect about a patient with dysphagia?

• A. The patient will find pureed or soft foods, such as custards, easier to swallow than water
• B. Fowler’s or semi Fowler’s position reduces the risk of aspiration during swallowing
• C. The patient should always feed himself
• D. The nurse should perform oral hygiene before assisting with feeding

Correct answer: C

Rationale: The incorrect statement is that 'The patient should always feed himself.' Patients with dysphagia may require assistance with feeding due to difficulty in swallowing safely. It is essential to provide appropriate support and supervision during meal times to prevent complications such as aspiration or inadequate nutrition intake.

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