Nursing Elites

1. The client provides three positive responses to the CAGE questionnaire. Which interpretation should the nurse provide?

• A. The CAGE is a tool for identifying substance abuse.
• B. Two positive responses suggest alcohol dependence.
• C. One positive response indicates potential alcohol issues.
• D. All responses must be positive for alcohol dependence.

Correct answer: B

Rationale: The CAGE questionnaire is a widely used screening tool for alcohol dependence. Two or more positive responses suggest a higher likelihood of alcohol dependence. One positive response may indicate potential alcohol issues, but two or more significantly increase the likelihood of dependence. Therefore, choice B is the most appropriate interpretation. Choice A is incorrect because the CAGE questionnaire specifically focuses on alcohol-related issues, not substance abuse in general. Choice C is incorrect as one positive response does not indicate addiction but rather raises a concern. Choice D is incorrect as not all responses need to be positive to suggest alcohol dependence.

2. A client with end-stage pulmonary disease requests 'no heroic measures' if she stops breathing. What should the nurse do next?

• A. Document the client's request in the medical record.
• B. Ask the client to discuss a DNR order with her healthcare provider.
• C. Consult the ethics committee for guidance.
• D. Discharge the client with no further discussion.

Correct answer: B

Rationale: The correct next step for the nurse is to ask the client to discuss a 'do not resuscitate' (DNR) order with her healthcare provider. While the client's wishes should be respected, it is essential to ensure proper documentation and legal protection by involving the healthcare provider in this decision-making process. Documenting the request in the medical record (Choice A) is important but should follow the discussion with the healthcare provider. Consulting the ethics committee (Choice C) may not be necessary at this stage and could delay the necessary actions. Discharging the client (Choice D) without further discussion is not appropriate and disregards the importance of addressing the client's wishes in a respectful and professional manner.

3. A client with chronic obstructive pulmonary disease (COPD) is receiving supplemental oxygen. The client reports feeling short of breath and has a respiratory rate of 28 breaths per minute. What should the nurse do first?

• A. Increase the oxygen flow rate
• B. Notify the healthcare provider
• C. Administer a bronchodilator
• D. Elevate the head of the bed

Correct answer: D

Rationale: Elevating the head of the bed promotes lung expansion and improves oxygenation, making it the priority intervention for a client with shortness of breath. This position helps in maximizing lung expansion and aiding ventilation-perfusion matching in patients with COPD. Increasing the oxygen flow rate may be necessary but should come after optimizing the client's positioning. Notifying the healthcare provider and administering a bronchodilator are not the initial interventions for addressing shortness of breath in a client with COPD.

4. A nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse?

• A. A client with a Dopamine drip IV with vital signs monitored every 5 minutes
• B. A client with a myocardial infarction that is free from pain and dysrhythmias
• C. A client with a tracheotomy of 24 hours in some respiratory distress
• D. A client with a pacemaker inserted this morning with intermittent capture

Correct answer: B

Rationale: In this scenario, it is more appropriate to assign a stable client, such as the one with a myocardial infarction who is free from pain and dysrhythmias, to a nurse who lacks specialized critical care experience. This client's condition is relatively stable and does not require immediate critical interventions. Choices A, C, and D involve clients with more complex and critical conditions that would be better managed by a nurse with specialized critical care training. Choice A involves a client on a Dopamine drip with frequent vital sign monitoring, Choice C has a client with a tracheotomy in respiratory distress, and Choice D describes a client with a pacemaker experiencing intermittent capture, all of which require a higher level of critical care expertise.

5. When assessing a recently delivered multigravida client, the nurse finds that her vaginal bleeding is more than expected. Which factor in this client's history is related to this finding?

• A. The client delivered a large baby
• B. She is a gravida 6, para 5
• C. The client had a cesarean delivery
• D. The client had a prolonged labor

Correct answer: B

Rationale: A client with a higher gravida and para count is at greater risk for uterine atony, which can lead to postpartum hemorrhage. The uterus may be less effective at contracting after multiple pregnancies, causing increased vaginal bleeding. Choices A, C, and D are incorrect because delivering a large baby, having a cesarean delivery, or experiencing prolonged labor do not directly correlate with an increased risk of postpartum hemorrhage in a multigravida client as compared to the gravida and para count.

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