Nursing Elites

1. While caring for a client who is postoperative and has refused to use an incentive spirometer following major abdominal surgery, what is the nurse's priority action?

• A. Request that a respiratory therapist discuss the technique for using the incentive spirometer
• B. Determine the reasons why the client is refusing to use the incentive spirometer
• C. Document the client's refusal to participate in health restorative activities
• D. Administer a pain medication to the client

Correct answer: B

Rationale: The nurse's priority is to determine the reasons why the client is refusing to use the incentive spirometer. By understanding the client's concerns or barriers, the nurse can address them appropriately. Requesting a respiratory therapist (Choice A) may be necessary later but is not the priority. Documenting the refusal (Choice C) is important but does not address the immediate need to assess and intervene. Administering pain medication (Choice D) without addressing the root cause of refusal is not appropriate and may mask the issue rather than resolve it.

2. The caregiver is assessing an 8-month-old child with atonic cerebral palsy. Which statement from the caregiver supports the presence of this problem?

• A. When I place my finger in the left hand, the baby does not respond with a grasp.
• B. My baby does not seem to track objects when I move toys in front of their face.
• C. When it thundered loudly last night, the baby did not even startle.
• D. When I place the baby in a supine position, that's how I find the baby.

Correct answer: D

Rationale: The statement 'When I place the baby in a supine position, that's how I find the baby' supports the presence of atonic cerebral palsy. In this type of cerebral palsy, the child may have poor muscle tone, making it difficult for them to roll from a back-lying position. This inability to roll indicates a lack of muscle tone, which is a characteristic feature of atonic cerebral palsy. Choices A, B, and C do not directly relate to the muscle tone issues typical of atonic cerebral palsy. Choice A focuses on a lack of grasp response, which may suggest motor issues but not specifically atonic cerebral palsy. Choice B refers to visual tracking, and choice C is about the startle reflex, neither of which are defining characteristics of atonic cerebral palsy.

3. A client with a history of falls is under the care of a nurse. Which of the following actions should be the nurse’s priority?

• A. Complete a fall-risk assessment.
• B. Educate the client and family about fall risks.
• C. Eliminate safety hazards from the client’s environment.
• D. Ensure the client uses assistive aids in their possession.

Correct answer: C

Rationale: The nurse's priority should be to eliminate safety hazards from the client's environment as it directly reduces the risk of falls. Addressing environmental hazards is an immediate and crucial step in preventing falls. While completing a fall-risk assessment is important to understand the client's risk factors, educating the client and family about fall risks is essential for prevention, and ensuring the use of assistive aids is crucial for safety, eliminating safety hazards takes precedence as it directly mitigates the risk of falls.

4. A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take?

• A. Discontinue the machine and measure the blood pressure manually every 15 minutes.
• B. Adjust the machine settings.
• C. Clean the machine to ensure accuracy.
• D. Increase the frequency of the readings.

Correct answer: B

Rationale: In this scenario, the nurse should adjust the machine settings. If the electronic blood pressure machine is providing varied intervals and inconsistent readings, it indicates a potential malfunction. Changing the settings may help correct the issue and ensure accurate measurements. Discontinuing the machine and measuring manually every 15 minutes (Choice A) may be time-consuming and impractical. Cleaning the machine (Choice C) is important for routine maintenance but may not address the current issue of varied intervals and inconsistent readings. Increasing the frequency of the readings (Choice D) does not address the problem of inaccurate measurements caused by the malfunctioning machine.

5. A client is admitted with a tentative diagnosis of congestive heart failure. Which of the following assessments would the nurse expect to be consistent with this problem?

• A. Chest pain
• B. Pallor
• C. Inspiratory crackles
• D. Heart murmur

Correct answer: C

Rationale: Inspiratory crackles are a common finding in patients with congestive heart failure due to the accumulation of fluid in the lungs, leading to crackling sounds during inspiration. Chest pain (Choice A) is more commonly associated with conditions like angina or myocardial infarction and is not a typical symptom of congestive heart failure. Pallor (Choice B) is a general symptom of various conditions and not specific to congestive heart failure. While a heart murmur (Choice D) may be heard in some cases of congestive heart failure, it is not as consistent as inspiratory crackles in indicating the condition.

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