Nursing Elites

1. During the care of a client with Legionnaire's disease, which finding would require the nurse's immediate attention?

• A. Pleuritic pain on inspiration
• B. Dry mucus membranes in the mouth
• C. A decrease in respiratory rate from 34 to 24
• D. Decrease in chest wall expansion

Correct answer: D

Rationale: A decrease in chest wall expansion suggests that the client may be experiencing a serious complication, such as worsening pneumonia or respiratory failure, requiring immediate medical attention. This finding indicates a potential decrease in lung function, which could lead to respiratory distress. Pleuritic pain on inspiration may be related to the disease process but does not indicate an immediate need for intervention. Dry mucus membranes in the mouth may require attention but are not as critical as a decrease in chest wall expansion. A decrease in respiratory rate could be concerning but is not as urgent as a decrease in chest wall expansion, which directly impacts respiratory function.

2. The nurse should consider the following when assessing the child for chest indrawing EXCEPT:

• A. Chest indrawing should be present at all times
• B. The lower chest wall does not go in when the child breathes in
• C. The lower chest goes in when the child breathes in
• D. The child should be calm

Correct answer: A

Rationale: The correct answer is A. Chest indrawing may not always be present and can vary with the child's activity level, so it should not be expected to be present at all times. Choice B is correct because the lower chest wall should not go in when the child breathes in. Choice C is correct as the lower chest should go in when the child breathes in, indicating chest indrawing. Choice D is correct as a calm child makes it easier to assess chest indrawing, but the absence of chest indrawing does not mean the child is not calm.

3. Building a healthy community is based on the following basic principles except:

• A. concreteness and reasoning to understand and solve problems
• B. human beings do not function independently but as a group
• C. the target of change is not individual or family but community
• D. environmental factors are more basic than institutional factors

Correct answer: D

Rationale: Building a healthy community is indeed based on principles like concreteness, group dynamics, and focusing on community-level change. However, stating that environmental factors are more basic than institutional factors is incorrect. Both environmental and institutional factors play crucial roles in community health. Environmental factors like access to healthcare, clean water, and safe housing are vital, while institutional factors such as healthcare systems, education, and governance also significantly impact community health. Therefore, the correct answer is D, as environmental factors are not more basic than institutional factors.

4. A client has developed thrombophlebitis of the left leg. Which nursing intervention should be given the highest priority?

• A. Elevate leg on 2 pillows
• B. Apply support stockings
• C. Apply warm compresses
• D. Maintain complete bed rest

Correct answer: A

Rationale: The highest priority nursing intervention for a client with thrombophlebitis of the left leg is to elevate the leg on 2 pillows. Elevating the leg helps reduce swelling and pain associated with thrombophlebitis by promoting venous return. Applying support stockings (choice B) can be beneficial but is not the highest priority as elevation is more effective in the acute phase. Applying warm compresses (choice C) may worsen the condition by dilating the blood vessels, leading to increased pain and swelling. Maintaining complete bed rest (choice D) is important, but elevation takes precedence to improve circulation and reduce the risk of complications.

5. Postoperative orders for a client undergoing a mitral valve replacement include monitoring pulmonary artery pressure together with pulmonary capillary wedge pressure with a pulmonary artery catheter. This action by the nurse will assess

• A. Right ventricular pressure
• B. Left ventricular end-diastolic pressure
• C. Acid-Base balance
• D. Coronary artery stability

Correct answer: B

Rationale: The correct answer is B: Left ventricular end-diastolic pressure. Pulmonary capillary wedge pressure is used to assess left ventricular end-diastolic pressure. This measurement provides valuable information on the filling pressure of the left ventricle. Choices A, C, and D are incorrect because monitoring pulmonary capillary wedge pressure does not directly assess right ventricular pressure, acid-base balance, or coronary artery stability.

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