Nursing Elites

1. A client in the emergency department is experiencing an acute asthma attack. Which assessment indicates an improvement in respiratory status?

• A. SaO2 95%
• B. Wheezing
• C. Retraction of sternal muscles
• D. Premature ventricular complexes (PVC's)

Correct answer: A

Rationale: An SaO2 of 95% indicates an improvement in the client's oxygen saturation, suggesting better respiratory status. In asthma exacerbation, a decrease in SaO2 levels would signal worsening respiratory distress. Wheezing, retraction of sternal muscles, and premature ventricular complexes are indicators of respiratory compromise and worsening respiratory status in acute asthma attacks. Monitoring SaO2 levels is crucial in assessing the effectiveness of interventions and guiding treatment decisions.

2. The healthcare professional must verify the client’s identity before the administration of medication. Which of the following is the safest way to identify the client?

• A. Ask the client for their name
• B. Check the client’s identification band
• C. State the client’s name aloud and ask the client to repeat it
• D. Check the room number

Correct answer: B

Rationale: Verifying the client's identity before administering medication is crucial to ensure patient safety. Checking the client’s identification band is the safest and most reliable method to confirm the client's identity. Identification bands are specifically designed to prevent errors in patient identification and help healthcare professionals administer care to the correct individual. Asking the client for their name (Choice A) may lead to errors if the client is unable to communicate or if there is a language barrier. Stating the client’s name aloud and asking them to repeat it (Choice C) relies on the client's ability to respond accurately. Checking the room number (Choice D) does not directly confirm the client's identity and may lead to errors if multiple patients are in the same room.

3. If a patient asks the nurse for her opinion about a particular physician and the nurse replies that the physician is incompetent, the nurse could be held liable for:

• A. Slander
• B. Libel
• C. Assault
• D. Respondent superior

Correct answer: A

Rationale: In this scenario, if the nurse makes a false verbal statement about the physician being incompetent, it is considered slander. Slander is the act of making defamatory spoken statements or gestures. Libel, on the other hand, refers to defamatory statements that are written or published. Assault involves the threat of physical harm, and respondent superior is a legal doctrine holding an employer responsible for the actions of an employee in the course of employment.

4. What is another name for the knee-chest position?

• A. Genu-dorsal
• B. Genu-pectoral
• C. Lithotomy
• D. Sim’s

Correct answer: B

Rationale: The knee-chest position is correctly identified as the genu-pectoral position. In this position, a person rests on their knees and chest with the abdomen raised and the head turned to one side. This position is commonly used in medical examinations and procedures involving the rectal or pelvic areas, allowing for better visualization and access. Choice A, 'Genu-dorsal,' is incorrect as it does not refer to the knee-chest position. Choice C, 'Lithotomy,' is incorrect as it refers to a position where the patient is lying on their back with legs flexed and feet in stirrups, commonly used during childbirth or certain surgeries. Choice D, 'Sim’s,' is incorrect as it refers to a position where the patient lies on their left side with the right knee and thigh drawn up with the left arm placed along the back.

5. A client who is at 38 weeks gestation, is in active labor, and has ruptured membranes is being cared for by a nurse. What action should the nurse take?

• A. Insert an indwelling urinary catheter
• B. Apply fetal heart rate monitor
• C. Initiate fundal massage
• D. Initiate an oxytocin IV infusion

Correct answer: B

Rationale: When caring for a client in active labor with ruptured membranes, the priority action for the nurse is to apply a fetal heart rate monitor. This helps monitor the well-being of the fetus during labor and delivery, enabling timely interventions if any fetal distress is detected. Inserting an indwelling urinary catheter may be required in some cases, but it is not the priority in the given scenario. Fundal massage is typically done after delivery to help the uterus contract and prevent postpartum hemorrhage. Initiating an oxytocin IV infusion may be indicated to augment labor, but it is not the initial action needed in this situation.

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