Nursing Elites

1. The nurse is caring for a comatose client. Which assessment finding provides the greatest indication that the client has an open airway?

• A. The client has asymmetrical chest expansion
• B. Percussion reveals dullness over the lung area
• C. Bilateral breath sounds can be auscultated
• D. The client has been turned q2h

Correct answer: C

Rationale: The correct answer is C: "Bilateral breath sounds can be auscultated." This finding indicates that air is moving adequately in and out of both lungs, confirming an open airway. Options A, B, and D are incorrect. Asymmetrical chest expansion may indicate lung or chest wall abnormalities, percussion revealing dullness over the lung area may suggest consolidation or fluid, and turning the client q2h is a position change intervention to prevent complications, not a direct assessment of airway patency.

2. A client with diabetes mellitus tells the nurse that she uses cranberry juice to help prevent urinary tract infection. What instruction should the nurse provide?

• A. Ensure to drink sugar-free cranberry juice
• B. Drinking cranberry juice does not prevent infection
• C. Cranberries do not affect insulin levels
• D. Excessive cranberry juice consumption can lead to constipation

Correct answer: B

Rationale: The correct answer is B: Drinking cranberry juice does not prevent urinary tract infections and should not be relied upon as a preventive measure. While cranberry juice is often associated with preventing UTIs, there is limited scientific evidence to support this claim. Choice A is incorrect because the sugar content in cranberry juice is not the main concern when discussing its role in preventing UTIs. Choice C is incorrect as there is no significant evidence to suggest cranberries affecting insulin levels. Choice D is incorrect as constipation is not a typical side effect of consuming cranberry juice; however, excessive consumption may lead to gastrointestinal discomfort.

3. A client with complaints of shortness of breath and abdominal pain 1 week after bariatric surgery is admitted for follow-up evaluation. Which assessment finding warrants immediate intervention by the nurse?

• A. Rectal temperature of 101°F
• B. Complaints of left shoulder pain
• C. Blood pressure of 88/50 mmHg
• D. Sustained sinus tachycardia

Correct answer: C

Rationale: A blood pressure of 88/50 mmHg indicates possible hypovolemia or shock, which requires immediate attention. Hypotension can be a sign of decreased perfusion to vital organs, potentially leading to organ failure. The other options, such as a rectal temperature of 101°F, complaints of left shoulder pain, or sustained sinus tachycardia, while important, do not present the same level of immediate threat to the client's well-being as a critically low blood pressure.

4. A group of nurses implemented a pilot study to evaluate a proposed evidence-based change to providing client care. Evaluation indicates successful outcomes, and the nurses want to integrate the change throughout the facility. Which action should be taken? (Select all that apply)

• A. Invite data review by the quality improvement department
• B. Submit a sentinel event report to the research committee
• C. Propose clinical practice guidelines to the nursing committee
• D. Arrange in-service training through the educational department

Correct answer: A

Rationale: Inviting data review by the quality improvement department is crucial to ensure the quality and efficacy of the proposed evidence-based change. This step allows for a comprehensive analysis of the data collected during the pilot study. Proposing clinical practice guidelines to the nursing committee is also essential for integrating the successful change into routine practice. In-service training through the educational department will help educate staff and ensure they are proficient in implementing the new practices. Submitting a sentinel event report to the research committee is not necessary in this scenario as the outcomes were successful, and there were no adverse events that would warrant such a report. Choices B, C, and D are not as relevant in this context compared to inviting data review by the quality improvement department, which is a crucial step in ensuring the success of the proposed change.

5. A client has a history of vasovagal attacks resulting in brady-dysrhythmias. Which instruction is most important to include in the teaching plan?

• A. Use stool softeners regularly
• B. Avoid electromagnetic fields
• C. Maintain a low-fat diet
• D. Do not use aspirin products

Correct answer: A

Rationale: The correct answer is A: 'Use stool softeners regularly.' Vasovagal attacks can be triggered by straining, and using stool softeners can help prevent such attacks. Choices B, C, and D are not directly related to preventing vasovagal attacks in this context. Avoiding electromagnetic fields, maintaining a low-fat diet, or not using aspirin products are important for various health reasons but not specifically for preventing vasovagal attacks related to brady-dysrhythmias.

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