Nursing Elites

1. During a well-child check-up, what respiratory assessment finding should the nurse anticipate in a 3-year-old?

• A. A resting respiratory rate of 40 breaths per minute
• B. Bronchovesicular breath sounds in the peripheral lung fields
• C. Retractions in the intercostal spaces with each inspiration
• D. High-pitched whistling sounds over the bronchi

Correct answer: A

Rationale: A resting respiratory rate of 40 breaths per minute is within the expected range for a 3-year-old child. This is considered normal in this age group as their respiratory rate is generally higher compared to adults. Bronchovesicular breath sounds in the peripheral lung fields are not an expected finding in a 3-year-old. Retractions in the intercostal spaces with each inspiration indicate increased work of breathing and are abnormal. High-pitched whistling sounds over the bronchi are characteristic of wheezing, which is not typically expected in a healthy 3-year-old during a routine check-up.

2. A client with multiple sclerosis is experiencing scotomas (blind spots), which are limiting peripheral vision. What intervention should the nurse include in this client's plan of care?

• A. Encourage the use of corrective lenses during the day
• B. Practice visual exercises that focus on a still object
• C. Alternate an eye patch from eye every 2 hours
• D. Teach techniques for scanning the environment

Correct answer: D

Rationale: The correct intervention for a client with multiple sclerosis experiencing scotomas and limited peripheral vision is to teach techniques for scanning the environment. This intervention helps the client compensate for vision loss by learning how to scan and explore their surroundings effectively. Encouraging the use of corrective lenses may not address the issue of scotomas, and visual exercises focusing on a still object may not enhance peripheral vision. Alternating an eye patch every 2 hours is not typically indicated for scotomas in multiple sclerosis, making it an incorrect choice.

3. A heparin infusion is prescribed for a client who weighs 220 pounds. After administering a bolus dose of 80 units/kg, the nurse calculates the infusion rate for the heparin sodium at 18 units/kg/hour. The available solution is Heparin Sodium 25,000 units in 5% Dextrose Injection 250 ml. The nurse should program the infusion pump to deliver how many ml/hour?

• A. 18
• B. 27
• C. 36
• D. 45

Correct answer: B

Rationale: To calculate the infusion rate, first, find the total dose required per hour, which is the patient's weight (220 pounds) multiplied by the prescribed rate (18 units/kg/hour). This equals 3960 units/hour. Next, determine how many ml of the solution contain 25,000 units; this is 250 ml. Divide the total dose required per hour (3960 units) by the units per ml (25,000 units/250 ml) to find how many ml are needed per hour. This results in 27 ml/hour. Therefore, the nurse should program the infusion pump to deliver 27 ml/hour. Choice A (18) is incorrect as it does not account for the concentration of the heparin solution. Choices C (36) and D (45) are incorrect as they do not reflect the accurate calculations based on the patient's weight and the heparin concentration in the solution.

4. The client enters the room of a client with Parkinson’s disease who is taking carbidopa-levodopa. The client is arising slowly from the chair while the unlicensed assistive personnel (UAP) stands next to the chair. What action should the nurse take?

• A. Demonstrate how to help the client move more efficiently
• B. Offer a PRN analgesic to reduce painful movement
• C. Affirm that the client should arise slowly from the chair
• D. Tell the UAP to assist the client in moving more quickly

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to demonstrate how to help the client move more efficiently. As the client is arising slowly from the chair, providing guidance on proper movement techniques can improve the client's mobility and safety. Offering a PRN analgesic (Choice B) is not relevant to the client's situation as there is no indication of pain. Affirming that the client should arise slowly (Choice C) does not address the need for assistance in improving movement efficiency. Instructing the UAP to assist the client in moving more quickly (Choice D) may compromise the client's safety and is not the appropriate action to take.

5. The nurse plans to collect a 24-hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client?

• A. Urinate at the specified time, discard this urine, and collect all subsequent urine over the next 24 hours.
• B. Cleanse around the meatus, discard the first portion of voiding, and collect the rest in a sterile bottle.
• C. For the next 24 hours, notify the nurse when the bladder is full, and the nurse will collect catheterized specimens.
• D. Urinate immediately into a urinal, and the lab will collect the specimen every 6 hours for the next 24 hours.

Correct answer: A

Rationale: The correct instruction for the adult male client to follow when collecting a 24-hour urine specimen for a creatinine clearance test is to urinate at the specified time, discard this urine, and collect all subsequent urine over the next 24 hours. This method ensures proper collection for an accurate creatinine clearance measurement. Choice B is incorrect as it describes a different procedure for a clean-catch urine sample, not suitable for creatinine clearance. Choice C is incorrect as it suggests catheterization, which is not typically done for a creatinine clearance test, and it is not necessary for this procedure. Choice D is incorrect as it does not follow the standard procedure for a 24-hour urine collection for creatinine clearance; the urine should be collected continuously over 24 hours, not at specified intervals.

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