Nursing Elites

1. A 57-year-old male client is scheduled to have a stress-thallium test the following morning and is NPO after midnight. At 0130, he is agitated because he cannot eat and is demanding food. Which response is best for the nurse to provide to this client?

• A. I'm sorry sir, you have a prescription for nothing by mouth from midnight tonight.
• B. I will let you have one cracker, but that is all you can have for the rest of tonight.
• C. What did the healthcare provider tell you about the test you are having tomorrow?
• D. The test you are having tomorrow requires that you have nothing by mouth tonight.

Correct answer: D

Rationale: Being direct and explaining to the client that the test requires him to be NPO, is the most therapeutic statement because the nurse is responding to the client's question and providing him the reason why.

2. In a patient with asthma, which of the following is a primary goal of treatment?

• A. Improving oxygenation.
• B. Reducing inflammation.
• C. Improving airflow.
• D. Reducing airway constriction.

Correct answer: C

Rationale: The primary goal in the treatment of asthma is to improve airflow. Asthma is characterized by airway inflammation, constriction, and increased mucus production, leading to airflow limitation. Improving airflow helps ensure adequate oxygenation and reduces symptoms. While reducing inflammation and airway constriction are important aspects of asthma management, the primary goal is to optimize airflow to improve respiratory function and quality of life.

3. What should the nurse do before an echocardiogram for a client who has had a myocardial infarction?

• A. Ensuring no food or drink for 4 hours before the procedure
• B. Obtaining informed consent from the client
• C. Assessing for any history of iodine or shellfish allergies
• D. Informing the client about the painless nature and duration of the procedure

Correct answer: D

Rationale: The correct answer is to inform the client that the echocardiogram is a painless procedure that usually takes 30 to 60 minutes to complete. Echocardiography is a noninvasive, risk-free, and pain-free test that uses ultrasound to evaluate the heart's structure and motion. There is no need for special preparation before the procedure. Choices A, B, and C are incorrect because imposing nothing-by-mouth status, obtaining informed consent, and assessing for allergies to iodine or shellfish are not necessary steps before an echocardiogram.

4. A client has the following arterial blood gas (ABG) results: pH 7.51, PCO2 31 mm Hg, PO2 94 mm Hg, HCO3 24 mEq/L. Which of the following acid-base disturbances does the nurse recognize in these results?

• A. Metabolic acidosis
• B. Metabolic alkalosis
• C. Respiratory acidosis
• D. Respiratory alkalosis

Correct answer: D

Rationale: The ABG results show a pH above the normal range (7.35-7.45) and a decreased PCO2, indicating respiratory alkalosis. In respiratory alkalosis, the pH is increased and the PCO2 is decreased. Metabolic acidosis (choice A) would present with a low pH and low HCO3 levels. Metabolic alkalosis (choice B) would show an increased pH and HCO3 levels. Respiratory acidosis (choice C) would have a low pH and an increased PCO2.

5. The nurse is caring for a client who is postoperative for a femoral head fracture repair. Which intervention(s) should the nurse plan to administer for deep vein thrombosis prophylaxis?

• A. Pneumatic compression devices
• B. Incentive spirometry
• C. Assisted ambulation
• D. Calf-pump exercises

Correct answer: A

Rationale: The correct intervention for deep vein thrombosis prophylaxis in a postoperative client with a femoral head fracture repair is the use of pneumatic compression devices. These devices help prevent stasis in the lower extremities by promoting venous return through intermittent compression. Incentive spirometry is used to prevent respiratory complications by promoting lung expansion and clearing secretions, not for DVT prophylaxis. Assisted ambulation and calf-pump exercises are beneficial for promoting circulation and preventing DVT, but pneumatic compression devices are more effective in this specific postoperative scenario.

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