Nursing Elites

1. A healthcare professional is assessing a client following a gunshot wound to the chest. For which of the following findings should the healthcare professional not monitor to detect a pneumothorax?

• A. Tachypnea
• B. Deviation of the trachea
• C. Bradycardia
• D. Pleuritic pain

Correct answer: C

Rationale: Bradycardia, which is a slow heart rate, is not typically associated with a pneumothorax. In a pneumothorax, the presence of air in the pleural space can lead to lung collapse, causing symptoms such as tachypnea (rapid breathing), deviation of the trachea, and pleuritic pain. Monitoring for bradycardia may not be as relevant in this context as it is not a typical indicator of a pneumothorax.

2. A client is being instructed on how to perform pursed-lip breathing. Which of the following should be included in the plan of care?

• A. Take quick breaths upon inhalation.
• B. Place your hand over your stomach.
• C. Take a deep breath in through your nose.
• D. Puff your cheeks upon exhalation.

Correct answer: C

Rationale: Pursed-lip breathing is a breathing technique that involves inhaling slowly through the nose and exhaling gently through pursed lips. This technique helps improve breathing efficiency and can be beneficial for individuals with respiratory conditions. Instructing the client to take a deep breath in through the nose is essential for proper execution of pursed-lip breathing, making choice C the correct answer.

3. The nurse observes that Mr. Adams begins to have increased difficulty breathing. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. The nurse documents this breathing as:

• A. Tachypnea
• B. Eupnea
• C. Orthopnea
• D. Hyperventilation

Correct answer: C

Rationale: Orthopnea is a condition where a person experiences difficulty breathing when lying flat but finds relief when sitting up or standing. Elevating the head of the bed to the high Fowler position helps alleviate this symptom. Tachypnea refers to rapid breathing, eupnea is normal breathing, and hyperventilation is breathing excessively fast or deep.

4. The client was asked to read the Snellen chart. Which of the following is being tested?

• A. Optic
• B. Olfactory
• C. Oculomotor
• D. Trochlear

Correct answer: A

Rationale: The correct answer is A: Optic. The Snellen chart is used to test visual acuity, which assesses the function of the optic nerve responsible for vision. Choices B, C, and D are incorrect. Olfactory relates to the sense of smell, oculomotor controls eye movement, and trochlear controls certain eye muscles. Therefore, the only option related to vision testing in this context is the optic nerve.

5. Which hormone is secreted by the Islets of Langerhans?

• A. Progesterone
• B. Testosterone
• C. Insulin
• D. Hemoglobin

Correct answer: C

Rationale: Insulin is the correct answer. It is the hormone secreted by the Islets of Langerhans in the pancreas. These specialized cells regulate blood sugar levels by releasing insulin in response to high blood glucose levels. Insulin aids in glucose absorption by cells, lowering blood sugar levels. Progesterone, testosterone, and hemoglobin are not secreted by the Islets of Langerhans and do not play a role in blood sugar regulation.

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