Nursing Elites

1. Using the illustrated technique, the healthcare provider is assessing for which finding in a patient with chronic obstructive pulmonary disease (COPD)?

• A. Hyperresonance
• B. Tripod positioning
• C. Accessory muscle use
• D. Reduced chest expansion

Correct answer: D

Rationale: The technique for palpation for chest expansion is shown in the illustrated technique. Reduced chest expansion would be noted on palpation of a patient's chest with COPD. Hyperresonance would be assessed through percussion, not palpation. Accessory muscle use and tripod positioning would be assessed by inspection, not palpation.

2. A client is found unresponsive in his room by a nurse. The client is not breathing and does not have a pulse. After calling for help, what is the next action the nurse should take?

• A. Administer 2 ventilations
• B. Perform a head-tilt, chin lift to open the airway
• C. Begin chest compressions
• D. Perform a jaw thrust to open the airway

Correct answer: C

Rationale: After finding an unresponsive client who is not breathing and has no pulse, the nurse's immediate action should be to call for help and start chest compressions. Chest compressions should be initiated at a rate of at least 100 per minute and a depth of at least 2 inches. Choice A, administering ventilations, is not the initial step as compressions take priority. Choice B, performing a head-tilt, chin lift, is also not the first step; chest compressions are crucial before airway management. Choice D, performing a jaw thrust, is typically used in cases of suspected cervical spine injury and is not the immediate action in this scenario.

3. Which action should the nurse take to evaluate treatment effectiveness for a patient who has hepatic encephalopathy?

• A. Ask the patient to extend both arms forward.
• B. Request that the patient walk with eyes closed.
• C. Ask the patient to perform the Valsalva maneuver.
• D. Observe the patient's breathing pattern.

Correct answer: B

Rationale: To evaluate treatment effectiveness for a patient with hepatic encephalopathy, requesting the patient to walk with eyes closed is crucial. This test assesses the patient's balance, gait, and coordination, which can be impaired in hepatic encephalopathy due to altered mental status and brain function. Walking with eyes closed challenges the patient's sensory input and proprioception, providing valuable information on improvement or deterioration in neurological function. Asking the patient to extend both arms forward is used to check for asterixis, a sign often seen in hepatic encephalopathy, but it is not specific for evaluating treatment effectiveness. Performing the Valsalva maneuver is unrelated to assessing hepatic encephalopathy and is more commonly used in cardiac evaluations. Observing the patient's breathing pattern may be important in other conditions but is not directly relevant to evaluating treatment effectiveness for hepatic encephalopathy.

4. A man is prescribed lithium to treat bipolar disorder. The nurse is most concerned about lithium toxicity when he notices which of these assessment findings?

• A. The patient states he had a manic episode a week ago
• B. The patient states he has been having diarrhea every day
• C. The patient presents as severely depressed
• D. The patient has a rash and pruritus on his arms and legs

Correct answer: B

Rationale: The correct answer is when the patient states he has been having diarrhea every day. Persistent diarrhea can lead to dehydration, which can increase the risk of lithium toxicity. The other options, such as a manic episode, severe depression, or rash and pruritus, are not directly associated with an increased risk of lithium toxicity.

5. Rhogam is most often used to treat____ mothers that have a ____ infant.

• A. RH positive, RH positive
• B. RH positive, RH negative
• C. RH negative, RH positive
• D. RH negative, RH negative

Correct answer: C

Rationale: Rhogam is administered to RH-negative mothers who have an RH-positive infant to prevent the development of anti-RH antibodies in the mother's system. Choice A (RH positive, RH positive) is incorrect because Rhogam is not used when both mother and infant are RH positive. Choice B (RH positive, RH negative) is incorrect because Rhogam is used when the mother is RH negative, not RH positive. Choice D (RH negative, RH negative) is incorrect as Rhogam is not typically needed if both mother and infant are RH negative.

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