Nursing Elites

1. A nurse is assessing a client with pneumonia. Which of the following findings should the nurse expect?

• A. Bradycardia
• B. Increased respiratory rate
• C. Decreased temperature
• D. Elevated blood pressure

Correct answer: B

Rationale: The correct answer is B: Increased respiratory rate. In pneumonia, the body tries to compensate for the reduced ability to oxygenate the blood by increasing the respiratory rate. This helps to improve oxygen exchange. Bradycardia (Choice A) is not typically associated with pneumonia, as an increased heart rate is more common due to the stress on the body. Decreased temperature (Choice C) is not a typical finding in pneumonia, as infections usually cause a fever. Elevated blood pressure (Choice D) is not a common finding in pneumonia unless there are complications such as sepsis.

2. A nurse is caring for a client at 32 weeks gestation with a history of cardiac disease. Which position should the nurse recommend to promote optimal cardiac output?

• A. The chest
• B. Standing
• C. Supine
• D. Left lateral

Correct answer: D

Rationale: The left lateral position is the correct choice to promote optimal cardiac output in a pregnant client at 32 weeks gestation with cardiac disease. This position improves venous return and decreases pressure on the vena cava, helping optimize cardiac output. Standing (choice B) would not be recommended as it may decrease venous return. The supine position (choice C) should be avoided in pregnant clients with cardiac disease as it can compress the vena cava, reducing cardiac output and potentially causing hypotension. The chest (choice A) is not a valid position recommendation for optimizing cardiac output in this scenario.

3. A healthcare provider is preparing to transfer a client from a chair to the bed. The client can bear partial weight and has upper body strength. Which device should the healthcare provider use?

• A. A wheelchair
• B. A stand-assist lift
• C. A transfer belt
• D. A slide board

Correct answer: B

Rationale: A stand-assist lift is the most suitable device for transferring a client who can bear partial weight and has upper body strength. This device provides support and assistance for the client to stand up and transfer safely. Choice A, a wheelchair, is not designed for this purpose and is used for mobility. Choice C, a transfer belt, is helpful for providing stability during transfers but may not be sufficient for a client with partial weight-bearing. Choice D, a slide board, is more suitable for transferring clients who are unable to bear weight and need assistance for lateral transfers.

4. Before administering blood products, which action should be taken?

• A. Assess the patient's temperature
• B. Document the patient’s response
• C. Prime IV tubing with 0.45% sodium chloride
• D. Administer epinephrine

Correct answer: A

Rationale: Before administering blood products, assessing the patient’s temperature is crucial. This action provides baseline data to detect any febrile reactions during or after the transfusion. Fever may indicate a transfusion reaction, so continuous monitoring of vital signs is essential throughout the procedure. Documenting the patient’s response (choice B) is important but comes after assessing the temperature. Priming IV tubing with 0.45% sodium chloride (choice C) is not directly related to the initial action required before administering blood products. Administering epinephrine (choice D) is not indicated unless there is a severe allergic reaction, which is not the standard initial step before blood product administration.

5. A nurse working in a mental health facility observes a client who has bipolar disorder walk over to a table occupied by other clients and knock their game off the table. Which of the following is an appropriate response by the nurse?

• A. Apologize to the others for your behavior.
• B. I am disappointed that you continue to act out when you are angry.
• C. Come outside with me for a walk.
• D. If you don't calm down, you will have to go into seclusion.

Correct answer: C

Rationale: Offering to go for a walk with the client helps redirect their energy in a non-confrontational way, avoiding escalation of aggressive behavior while promoting de-escalation.

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