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. When discussing hair loss with Mrs. Lim, who begins to cry, the best response would be:

• A. Don’t worry. It’s only temporary
• B. Why are you crying? I didn’t get to the bad news yet
• C. Your hair is really pretty
• D. I know this will be difficult for you, but your hair will grow back after the completion of chemotherapy

Correct answer: D

Rationale: When a patient is emotionally affected, it is essential to acknowledge their feelings while providing reassurance and information. Option D demonstrates empathy by acknowledging the difficulty Mrs. Lim is facing and offers hope by reassuring her that her hair will grow back after chemotherapy, which can provide comfort and support during a challenging time.

3. A client has unilateral paralysis and dysphagia following a right hemispheric stroke. Which of the following interventions should the nurse include in the plan?

• A. Place the client's left arm on a pillow while he is sitting.
• B. Provide total care in assisting with the client's ADLs.
• C. Encourage mobility and avoid bed rest.
• D. Facilitate feeding by placing food on the left side of the client's mouth when ready to eat.

Correct answer: A

Rationale: Placing the client's left arm on a pillow while sitting helps prevent shoulder displacement and assists in maintaining proper positioning and alignment. This intervention is crucial to prevent complications associated with immobility. Providing total care in ADLs may hinder the client's independence and recovery. Encouraging mobility is essential in preventing complications of immobility. Facilitating feeding by placing food on the unaffected side of the mouth helps reduce the risk of aspiration in clients with dysphagia.

4. Palpating the midclavicular line is the correct technique for assessing

• A. Baseline vital signs
• B. Systolic blood pressure
• C. Respiratory rate
• D. Apical pulse

Correct answer: D

Rationale: Palpating the midclavicular line is the correct technique for assessing the apical pulse. The apical pulse is located at the point of maximal impulse (PMI), which is typically at the fifth intercostal space at the midclavicular line. This technique allows healthcare providers to accurately assess the heart rate and rhythm by listening to the heart sounds directly at this point.

5. Which of the following blood tests should be performed before a blood transfusion?

• A. Prothrombin and coagulation time
• B. Blood typing and cross-matching
• C. Bleeding and clotting time
• D. Complete blood count (CBC) and electrolyte levels

Correct answer: B

Rationale: Before administering a blood transfusion, it is crucial to perform blood typing and cross-matching to ensure compatibility between the donor's blood and the recipient's blood. This process helps prevent adverse reactions such as transfusion reactions, which can be life-threatening. Prothrombin and coagulation time, bleeding and clotting time, as well as CBC and electrolyte levels are important tests in other clinical contexts, but for blood transfusions, blood typing and cross-matching are essential to ensure patient safety.

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