Nursing Elites

1. When caring for a client with acute respiratory distress syndrome (ARDS), why does the nurse elevate the head of the bed 30 degrees?

• A. To reduce abdominal pressure on the diaphragm
• B. To promote retraction of the intercostal accessory muscles of respiration
• C. To promote bronchodilation and effective airway clearance
• D. To decrease pressure on the medullary center which stimulates breathing

Correct answer: A

Rationale: Elevating the head of the bed to 30 degrees is done to reduce abdominal pressure on the diaphragm, aiding in lung expansion and oxygenation. This position helps improve respiratory mechanics by allowing the diaphragm to move more effectively. Choice B is incorrect as elevating the head of the bed does not directly promote retraction of the intercostal accessory muscles of respiration. Choice C is incorrect because although elevating the head of the bed can assist with airway clearance, its primary purpose in ARDS is to decrease pressure on the diaphragm. Choice D is incorrect because reducing pressure on the medullary center is not the main goal of elevating the head of the bed; the focus is on enhancing lung function and oxygen exchange.

2. Which laboratory finding should the nurse expect to see in a child with acute rheumatic fever?

• A. Thrombocytopenia
• B. Polycythemia
• C. Decreased ESR
• D. Positive ASO titer

Correct answer: D

Rationale: The correct answer is D: Positive ASO titer. A positive ASO titer indicates recent streptococcal infection, which is associated with acute rheumatic fever. Thrombocytopenia (choice A) is not a typical laboratory finding in acute rheumatic fever. Polycythemia (choice B) refers to an increased red blood cell count, which is not typically seen in acute rheumatic fever. Decreased ESR (choice C) is not a common laboratory finding in acute rheumatic fever; in fact, ESR is often elevated in inflammatory conditions like rheumatic fever.

3. A 46-year-old male client who had a myocardial infarction 24 hours ago comes to the nurse’s station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which nursing problem should the nurse formulate?

• A. Anxiety related to treatment plan
• B. Deficient knowledge of lifestyle changes
• C. Ineffective coping related to denial
• D. Decisional conflict due to stress

Correct answer: C

Rationale: The correct answer is C: 'Ineffective coping related to denial.' The client's behavior of wanting to go home and feeling much better shortly after a myocardial infarction indicates denial of the severity of his condition. This denial can lead to ineffective coping mechanisms, hindering his recovery and treatment. Choices A, B, and D are incorrect because the client's behavior is not primarily driven by anxiety about the treatment plan, deficient knowledge of lifestyle changes, or decisional conflict due to stress, but rather by denial and ineffective coping mechanisms.

4. Two days after an abdominal hysterectomy, an elderly female with diabetes has a syncopal episode. The nurse determines that her vital signs are within normal limits, but her blood sugar is 325 mg/dL or 18.04 mmol/L (SI). What intervention should the nurse implement first?

• A. Administer regular insulin per sliding scale
• B. Cancel the client's dinner tray
• C. Give the client 4 ounces (120 mL) of orange juice
• D. Administer the next scheduled dose of metformin

Correct answer: A

Rationale: In this case, the nurse should implement the intervention of administering regular insulin per sliding scale. High blood sugar levels, as indicated by a reading of 325 mg/dL, require insulin administration to prevent complications such as hyperglycemia. Canceling the client's dinner tray (choice B) would not address the immediate need to lower the blood sugar level. Giving the client orange juice (choice C) might further increase the blood sugar level as it contains sugar. Administering the next scheduled dose of metformin (choice D) is not appropriate as metformin is not typically used for acute management of high blood sugar levels.

5. A male client admitted three days ago with respiratory failure is intubated and receiving 40% oxygen per facemask. Currently, his temperature is 99°F, capillary refill is less than 4 seconds, and respiratory effort is within normal limits. What outcome should the nurse evaluate to measure for successful extubation?

• A. Exhibits adequate tissue perfusion
• B. Remains free of injury
• C. Remains free of infection
• D. Maintains effective breathing pattern

Correct answer: D

Rationale: Successful extubation is primarily measured by the client's ability to maintain an effective breathing pattern. This indicates that the client can adequately oxygenate and ventilate without the need for artificial airway support. Choices A, B, and C are important aspects of patient care but are not the primary outcomes to evaluate for successful extubation. Adequate tissue perfusion, freedom from injury, and prevention of infection are ongoing goals during the client's hospitalization but are not the immediate focus when considering extubation.

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