Nursing Elites

1. A patient with acute dyspnea is scheduled for a spiral computed tomography (CT) scan. Which information obtained by the nurse is a priority to communicate to the health care provider before the CT?

• A. Allergy to shellfish
• B. Apical pulse of 104
• C. Respiratory rate of 30
• D. Oxygen saturation of 90%

Correct answer: A

Rationale: Because iodine-based contrast media is used during a spiral CT, the patient may need to have the CT scan without contrast or be premedicated before injection of the contrast media. The increased pulse, low oxygen saturation, and tachypnea all indicate a need for further assessment or intervention but do not indicate a need to modify the CT procedure.

2. The healthcare provider is reviewing the lab results of a patient who has presented in the Emergency Room. The lab results show that the troponin T value is at 5.3 ng/mL. Which of these interventions, if not already completed, would take priority over the others?

• A. Place the patient in a 90-degree position
• B. Assess whether the patient is taking diuretics
• C. Obtain and attach defibrillator leads
• D. Assess the patient's last ejection fraction

Correct answer: C

Rationale: In this scenario, the elevated Troponin T level indicates cardiac damage, possibly due to a myocardial infarction. A Troponin T value of 5.3 ng/mL is significantly elevated (normal levels are below 0.2 ng/mL), suggesting acute cardiac injury. Given the setting of an Emergency Room and the critical nature of the situation, the priority intervention should be to obtain and attach defibrillator leads. Elevated Troponin T levels can indicate a higher risk of arrhythmias, including ventricular fibrillation, which can lead to sudden cardiac arrest. Defibrillator leads are essential for monitoring the patient's cardiac rhythm and readiness for immediate defibrillation if necessary. Placing the patient in a 90-degree position (Choice A) or assessing diuretic use (Choice B) are not immediate priorities in this critical situation. Additionally, assessing the patient's last ejection fraction (Choice D) is important but not as urgent as preparing for potential life-threatening arrhythmias requiring defibrillation.

3. A clinic nurse interviews a parent who is suspected of abusing her child. Which of the following characteristics is the nurse least likely to find in an abusing parent?

• A. Low self-esteem
• B. Unemployment
• C. Self-blame for the injury to the child
• D. Single status

Correct answer: C

Rationale: The profile of a parent at risk of abusive behavior includes a tendency to blame the child or others for the injury sustained. Abusers typically blame others, especially their partners, for the mistakes in their lives. This is related to hypersensitivity, but they are not necessarily alike. This occurs because most abusive people don't hold themselves as being accountable for the actions they commit. Instead, they'll try to shift the blame to the person that they have abused and somehow say they "deserved it"? or that they were forced into a corner.

4. During the admission assessment of a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate due to this condition?

• A. "I have constant blurred vision."?
• B. "I can't see on my left side."?
• C. "I have to turn my head to see my room."?
• D. "I have specks floating in my eyes."?

Correct answer: C

Rationale: In chronic bilateral glaucoma, peripheral visual field loss occurs due to elevated intraocular pressure, leading to the need to turn the head to compensate for the visual field deficit. This symptom is characteristic of advanced glaucoma. Choice A is incorrect as constant blurred vision is a common symptom but not specific to peripheral vision loss in glaucoma. Choice B is incorrect because specific visual field deficits are more common than complete loss on one side. Choice D is incorrect as seeing floaters (specks floating in the eyes) is associated with other eye conditions like posterior vitreous detachment, not glaucoma.

5. The nurse notes that a patient has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which action should the nurse take first?

• A. Assist the patient to sit upright in a chair.
• B. Splint the patient's chest during coughing.
• C. Medicate the patient with prescribed morphine.
• D. Observe the patient use the incentive spirometer.

Correct answer: C

Rationale: The correct answer is to medicate the patient with prescribed morphine. A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain, which can worsen with deep breathing and coughing. The priority is to address the incisional pain to facilitate effective coughing and deep breathing, which are essential for clearing the airways and preventing complications. Assisting the patient to sit upright, splinting the patient's chest during coughing, and observing the patient using the incentive spirometer are all appropriate interventions to improve airway clearance, but they should be implemented after addressing the incisional pain with medication.

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