Nursing Elites

1. The healthcare provider is conducting a respiratory assessment and is determining respirations per minute. Which factor(s) generally affect the character of respirations? Select all that apply.

• A. Anxiety
• B. Exercise
• C. Smoking
• D. A, B

Correct answer: D

Rationale: Correct! Anxiety and exercise can significantly alter the character of respirations, increasing the rate and depth. Smoking, while harmful to the respiratory system in the long term, does not directly affect the character of respirations like anxiety and exercise do. Therefore, choices C (Smoking) is incorrect. The correct answer is D (A, B).

2. The nurse is preparing to assist in examining a Hispanic child who was brought to the clinic by the mother. During the assessment of the child, the nurse should take which action(s)?

• A. Building rapport with the child
• B. Taking the child’s temperature
• C. A, D
• D. Obtaining an interpreter if necessary

Correct answer: C

Rationale: Building rapport with the child is essential to establish trust and cooperation during the assessment. Admiring the child may not be appropriate in a professional setting and might not contribute significantly to the assessment. Taking the child's temperature is a routine part of the assessment but may not be the most critical action in this scenario. Obtaining an interpreter is crucial to ensure effective communication between the healthcare team and the child and their mother, especially considering potential language barriers.

3. When palpating the client's neck for lymphadenopathy, where should the nurse position himself?

• A. At the client's back
• B. At the client's right side
• C. At the client's left side
• D. In front of a sitting client

Correct answer: D

Rationale: When palpating the client's neck for lymphadenopathy, the nurse should position himself in front of a sitting client. This positioning allows for easier access to the neck area and better visualization of any swelling or abnormalities in the lymph nodes. Being in front of the client ensures proper alignment and comfort for both the nurse and the client during the assessment. Choices A, B, and C are incorrect because positioning at the client's back or sides would make it challenging to adequately palpate the neck area and assess for lymphadenopathy.

4. In a routine sputum analysis, which of the following indicates proper nursing action before sputum collection?

• A. Secure a clean container
• B. Discard the container if the outside becomes dirty
• C. Rinse the client's mouth with Listerine before collection
• D. Tell the client that 4 tablespoons of sputum are needed

Correct answer: A

Rationale: The correct answer is to secure a clean container before sputum collection. This is essential to prevent contamination of the specimen, ensuring accurate test results and avoiding the introduction of external particles or bacteria. Choice B is incorrect because discarding the container if the outside becomes dirty is not necessary; the cleanliness of the inside is crucial. Choice C is incorrect as rinsing the client's mouth with Listerine before collection may introduce unwanted substances that can affect the test results. Choice D is incorrect as the amount of sputum required can vary depending on the test, and specifying a specific amount without medical guidance is not appropriate.

5. The client is diagnosed with hereditary spherocytosis. Which treatment/procedure would the nurse prepare the client to receive?

• A. Bone marrow transplant
• B. Splenectomy
• C. Frequent blood transfusions
• D. Liver biopsy

Correct answer: B

Rationale: The correct answer is B: Splenectomy. Splenectomy is the treatment of choice for hereditary spherocytosis as it helps prevent hemolysis and improve anemia. Removing the spleen reduces the destruction of the abnormal red blood cells. Choice A, Bone marrow transplant, is not a standard treatment for hereditary spherocytosis. Choice C, Frequent blood transfusions, may be used to manage anemia in some cases but is not the primary treatment for hereditary spherocytosis. Choice D, Liver biopsy, is not a treatment for hereditary spherocytosis; it is a procedure used to diagnose liver conditions, not related to this hematologic disorder.

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