Nursing Elites

1. A client is having blood tests and has an elevated lymphocyte level. Based on knowledge of cellular components, what does the nurse know about these cells?

• A. Contain histamine and provide protection during allergic reactions
• B. Are involved in phagocytosis
• C. Provide protection and immunity against foreign substances
• D. Carry hemoglobin and oxygen to body tissues

Correct answer: C

Rationale: Lymphocytes are a type of white blood cells that play a crucial role in supporting the body's immune system. They are responsible for producing substances that protect the body against infections and foreign substances that could potentially harm the client. Lymphocytes consist of two main types: T cells, which are produced in the thymus, and B cells, which are produced in the lymphatic tissue. Choice A is incorrect because histamine is mainly associated with basophils and mast cells, not lymphocytes. Choice B is incorrect as phagocytosis is a function of other white blood cells such as neutrophils and macrophages. Choice D is also incorrect as carrying hemoglobin and oxygen is a function of red blood cells, not lymphocytes.

2. When should discharge training and planning begin for a 65-year-old man admitted to the hospital for spinal stenosis surgery?

• A. Following surgery
• B. Upon admission
• C. Within 48 hours of discharge
• D. Preoperative discussion

Correct answer: B

Rationale: Discharge training and planning should begin upon admission for a patient undergoing spinal stenosis surgery. It is crucial to initiate this process early to ensure a smooth transition from hospital care to home or a rehabilitation facility. Starting discharge planning upon admission allows for comprehensive involvement of the patient, family, and healthcare team, which can reduce the risk of readmission, optimize recovery, ensure proper medication management, and adequately prepare caregivers. Therefore, option B, 'Upon admission,' is the correct answer. Options A, C, and D are incorrect because waiting until after surgery, within 48 hours of discharge, or during preoperative discussion would not provide sufficient time for effective discharge planning and education.

3. Mr. N is a client who entered the hospital with a diagnosis of diabetic ketoacidosis. The nurse enters his room to check his vital signs and finds him breathing at a rate of 32 times per minute; his respirations are deep and regular. Which type of respiratory pattern is Mr. N most likely exhibiting?

• A. Kussmaul respirations
• B. Cheyne-Stokes respirations
• C. Biot's respirations
• D. Cluster breathing

Correct answer: A

Rationale: Mr. N is most likely exhibiting Kussmaul respirations. Kussmaul respirations are a form of hyperventilation associated with conditions like metabolic acidosis. They are characterized by rapid, regular, and deep breathing. This type of respiratory pattern helps the body compensate for metabolic acidosis by attempting to blow off excess carbon dioxide. This pattern is different from Cheyne-Stokes respirations (choice B), which are characterized by alternating periods of deep, rapid breathing followed by apnea. Biot's respirations (choice C) are characterized by groups of quick, shallow inspirations followed by irregular periods of apnea, and Cluster breathing (choice D) involves clusters of breaths followed by periods of apnea, often seen in patients with brain injury or neurological conditions.

4. Which of the following is an example of restorative care?

• A. A nurse teaches a new mother how to breastfeed her infant
• B. A nurse helps a client with developing a bladder-retraining program
• C. A nurse places an allergy wristband on a client's wrist to notify other providers of potential reactions
• D. A nurse contacts the family of a client to tell them he will be out of surgery soon

Correct answer: B

Rationale: Restorative care involves assisting clients in regaining or maintaining their highest possible level of function. This type of care focuses on promoting self-care and independence by helping clients perform activities that enhance their functional abilities. In this scenario, a nurse who assists a client with developing a bladder-retraining program is engaging in restorative care by helping the client regain bladder function. Choices A, C, and D do not represent restorative care. Teaching a new mother how to breastfeed her infant (Choice A) is an example of educative care, placing an allergy wristband (Choice C) is a safety measure, and contacting a client's family to update them on surgery (Choice D) is related to communication and support, not restorative care.

5. Mr. N is a client who entered the hospital with a diagnosis of diabetic ketoacidosis. The nurse enters his room to check his vital signs and finds him breathing at a rate of 32 times per minute; his respirations are deep and regular. Which type of respiratory pattern is Mr. N most likely exhibiting?

• A. Kussmaul respirations
• B. Cheyne-Stokes respirations
• C. Biot's respirations
• D. Cluster breathing

Correct answer: A

Rationale: Mr. N is exhibiting Kussmaul respirations, characterized by rapid, deep, and regular breathing. This type of respiratory pattern is commonly seen in metabolic acidosis, such as in diabetic ketoacidosis. Kussmaul respirations are a form of hyperventilation, leading to the elimination of carbon dioxide from the body. Choice B, Cheyne-Stokes respirations, is characterized by alternating periods of deep, rapid breathing followed by periods of apnea and is not typically associated with diabetic ketoacidosis. Choice C, Biot's respirations, involve irregular breathing patterns with periods of apnea and are not reflective of the described breathing pattern. Cluster breathing, as mentioned in Choice D, is not a recognized term in respiratory patterns and does not describe the breathing pattern observed in Mr. N.

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