Nursing Elites

1. The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment?

• A. Have the patient lie down to obtain an accurate cardiac, respiratory, and abdominal assessment.
• B. Obtain a thorough history and physical assessment from the patient's family member.
• C. Immediately perform a complete history and physical assessment to obtain baseline information.
• D. Examine the body areas relevant to the problem and complete the rest of the assessment after the problem has resolved.

Correct answer: D

Rationale: When assessing a patient experiencing significant shortness of breath, it is crucial to prioritize the evaluation of areas directly related to the problem. Having the patient lie down may exacerbate the breathing difficulty. Therefore, the nurse should focus on examining the body areas pertinent to the issue, such as the respiratory and cardiac systems. Completing the rest of the assessment can be deferred until after addressing the immediate problem. Obtaining a complete history or involving family members should come after addressing the acute issue to ensure the patient's safety and comfort.

2. You see a sign over Mary Jones' bed when you arrive at 7 am to begin your day shift. The sign says, 'NPO'. Ms. Jones is on a regular diet. The patient asks for milk and some crackers. You _____________.

• A. can give her the milk but not the crackers
• B. can give her both the milk and the crackers
• C. can give her the crackers but not the milk
• D. cannot give her anything to eat or drink

Correct answer: D

Rationale: The correct answer is that you cannot give her anything to eat or drink. 'NPO' is the standard abbreviation for 'nothing by mouth,' indicating that the patient should not consume any food or liquids. It is crucial to adhere to this restriction to prevent any potential harm or complications in the patient's condition. Choices A, B, and C are incorrect because 'NPO' clearly specifies that the patient should not have anything to eat or drink, including milk and crackers. Providing these items could lead to adverse effects, so it is essential to follow the 'NPO' directive strictly.

3. Each small square on the EKG paper is:

• A. 0.04 seconds long and 5mm tall
• B. 0.2 seconds long and 5mm tall
• C. 0.04 seconds long and 20mm tall
• D. 0.04 seconds long and 1mm tall

Correct answer: D

Rationale: Each small square on an EKG paper represents 0.04 seconds long and 1mm tall. This standardization is essential for accurate measurements. One large square on EKG paper consists of 5 small squares in length and 5 small squares in height, which equals 0.2 seconds long and 5mm tall (0.5 mV). Choice A is incorrect because while the duration is correct, the height mentioned is not accurate. Choice B is incorrect as it provides the correct height but the duration is inaccurate. Choice C is incorrect as the height mentioned is exaggerated, and the duration is correct but the height is not. Therefore, the correct answer is 0.04 seconds long and 1mm tall.

4. Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?

• A. Listen to a patient's lung sounds for wheezes or rhonchi.
• B. Label specimens obtained during percutaneous lung biopsy.
• C. Instruct a patient about how to use home spirometry testing.
• D. Measure induration at the site of a patient's intradermal skin test.

Correct answer: B

Rationale: Labeling specimens obtained during a percutaneous lung biopsy is a task that can be appropriately delegated to unlicensed assistive personnel (UAP) as it does not require nursing judgment. UAP can perform this task safely under the supervision of a nurse. Listening to a patient's lung sounds for wheezes or rhonchi, instructing a patient about how to use home spirometry testing, and measuring induration at the site of a patient's intradermal skin test all require nursing judgment and interpretation of findings. These tasks should be performed by licensed nursing personnel to ensure accurate assessment and appropriate intervention.

5. Which of the following may represent an upper airway obstruction?

• A. Retractions
• B. Elongated expiratory phase
• C. Stridor
• D. Expiratory wheezing

Correct answer: C

Rationale: Stridor is the sound produced by turbulent airflow through a partially obstructed upper airway. It is a classic sign of upper airway obstruction. While an elongated expiratory phase may indicate lower airway obstruction, stridor specifically points to an upper airway issue. Retractions are also often seen in upper airway obstruction due to the increased effort of breathing. Expiratory wheezing, on the other hand, is more indicative of lower airway conditions such as asthma or chronic obstructive pulmonary disease (COPD).

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