Nursing Elites

1. Which oxygen delivery system would provide the highest concentrations of oxygen to the client?

• A. Venturi mask
• B. Partial rebreather mask
• C. Non-rebreather mask
• D. Simple face mask

Correct answer: C

Rationale: The correct answer is the non-rebreather mask. This oxygen delivery system has a one-way valve that prevents exhaled air from entering the reservoir bag and one or more valves covering the air holes on the face mask itself to prevent the inhalation of room air but allow exhalation of air. When a tight seal is achieved around the mask, up to 100% of oxygen is available. Choice A, the Venturi mask, delivers precise oxygen concentrations but not as high as the non-rebreather mask. Choice B, the partial rebreather mask, allows the client to rebreathe some exhaled air, resulting in lower oxygen concentrations than the non-rebreather mask. Choice D, the simple face mask, delivers low to moderate oxygen concentrations and is not designed to provide the highest concentrations like the non-rebreather mask.

2. After surgery for an imperforate anus, an infant returns with a red and edematous colostomy stoma. What action should the nurse take based on this finding?

• A. Elevate the buttocks.
• B. Document the findings.
• C. Apply ice immediately.
• D. Call the primary health care provider.

Correct answer: B

Rationale: A red and edematous colostomy stoma is a common finding immediately after surgery, and these changes are expected to decrease over time. As the stoma heals, it usually becomes pink without signs of abnormal drainage, swelling, or skin breakdown. Therefore, the appropriate action for the nurse is to document these normal findings. Elevating the buttocks, applying ice, or calling the primary health care provider are unnecessary interventions at this stage.

3. A nurse is caring for a patient after a coronary angiogram. Which of these actions taken by the nursing assistant would most require the nurse's immediate intervention?

• A. The nursing assistant fills the patient's pitcher with ice-cold drinking water
• B. The nursing assistant elevates the head of the bed to 60 degrees for a meal
• C. The nursing assistant refills the ice pack placed on the insertion site
• D. The nursing assistant places an extra pillow under the patient's head upon request

Correct answer: B

Rationale: After a coronary angiogram, patients need to maintain bed rest and keep the head of the bed at no more than 30 degrees for 3-6 hours, depending on the insertion site. Elevating the head of the bed to 60 degrees for a meal could increase the risk of bleeding or complications at the insertion site. Refilling the ice pack placed on the insertion site is appropriate for managing potential swelling or discomfort. Filling the patient's pitcher with ice-cold drinking water is a standard care task. Placing an extra pillow under the patient's head upon request is a comfort measure and does not pose a risk to the patient's recovery.

4. A patient with newly diagnosed lung cancer tells the nurse, 'I don't think I'm going to live to see my next birthday.' Which response by the nurse is best?

• A. Would you like to talk to the hospital chaplain about your feelings?
• B. Can you tell me what it is that makes you think you will die so soon?
• C. Are you afraid that the treatment for your cancer will not be effective?
• D. Do you think that taking an antidepressant medication would be helpful?

Correct answer: B

Rationale: The nurse's initial response should be to collect more assessment data about the patient's statement. The answer beginning 'Can you tell me what it is' is the most open-ended question and will offer the best opportunity for obtaining more data. The answer beginning 'Are you afraid' implies that the patient thinks that the cancer will be immediately fatal, although the patient's statement may not be related to the cancer diagnosis. The remaining two answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether these interventions are appropriate.

5. A client is in her third month of her first pregnancy. During the interview, she tells the nurse that she has several sex partners and is unsure of the identity of the baby's father. Which of the following nursing interventions is a priority?

• A. Counsel the woman to consent to HIV screening
• B. Perform tests for sexually transmitted diseases
• C. Discuss her high risk for cervical cancer
• D. Refer the client to a family planning clinic

Correct answer: A

Rationale: Counsel the woman to consent to HIV screening. The client's behavior places her at high risk for HIV. Testing is the first step in identifying and managing the risk of HIV infection. Early detection allows for timely interventions and better outcomes. While performing tests for sexually transmitted diseases (choice B) is important, addressing the immediate and potentially life-threatening risk of HIV takes precedence. Discussing the risk for cervical cancer (choice C) is not the priority at this time as HIV screening is more urgent. Referring the client to a family planning clinic (choice D) is not the immediate priority given the client's current high-risk behavior and the need to address the immediate threat of HIV infection.

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