Nursing Elites

1. Which statement by the client with chronic obstructive lung disease indicates an understanding of the major reason for the use of occasional pursed-lip breathing?

• A. ''This action of my lips helps to keep my airway open.''
• B. ''I can expel more air when I pucker up my lips to breathe out.''
• C. ''My mouth doesn't get as dry when I breathe with pursed lips.''
• D. ''By prolonging breathing out with pursed lips, the smaller areas in my lungs don't collapse.''

Correct answer: D

Rationale: The correct answer is D. Clients with chronic obstructive pulmonary disease have difficulty exhaling fully due to the weak alveolar walls from the disease process. Pursed-lip breathing helps prevent alveolar collapse by maintaining positive pressure in the airways during exhalation. This is the major reason for using pursed-lip breathing in individuals with chronic obstructive lung disease. Choices A, B, and C are incorrect because they do not directly address the main purpose of pursed-lip breathing, which is to prevent alveolar collapse and improve exhalation in these patients.

2. Which of the following situations indicates the need to file an incident report?

• A. The neon sign directing parking for visitors has burned out
• B. A nurse must send a syringe pump to maintenance for annual service
• C. A client's blood pressure dropped to 90/55 after receiving a dose of morphine
• D. A client's spouse becomes angry and is asked to leave the premises

Correct answer: D

Rationale: An incident report is necessary for documenting unexpected events that occur in a healthcare setting. Situations that warrant filing an incident report include client accidents, medication errors, security problems, or disruptive behaviors that involve clients, families, or visitors. In this scenario, when a client's spouse displays disruptive behavior and is asked to leave the premises, it is essential to document this incident to ensure a record of the event and its resolution. Choices A, B, and C do not involve disruptive behavior or safety concerns that would require an incident report to be filed.

3. According to the American Heart Association standards, high-quality CPR for an adult includes all of the following EXCEPT:

• A. Push hard
• B. Push fast
• C. Allow chest recoil between compressions
• D. Pause CPR as each drug is administered

Correct answer: D

Rationale: High-quality CPR for adults should not be paused for drug administration. The correct CPR technique involves pushing hard and fast, at a rate of at least 100 compressions per minute and to a depth of at least 2 inches. It is also essential to allow chest recoil between compressions to enable proper blood circulation. Pausing CPR for drug administration would delay the delivery of continuous chest compressions, which are crucial for maintaining blood flow and oxygenation during cardiac arrest.

4. The nurse is comparing the concepts of religion and spirituality. Which statement describes an appropriate component of one's spirituality?

• A. Belief in and worship of God or gods
• B. Being closely tied to one's ethnic background
• C. Attendance at a specific church or place of worship
• D. A connection with something larger than oneself and belief in transcendence

Correct answer: D

Rationale: Spirituality refers to a connection with something larger than oneself and a belief in transcendence. The other responses do not apply to spirituality. Choice A, 'Belief in and worship of God or gods,' and choice C, 'Attendance at a specific church or place of worship,' are more aligned with religious practices. Choice B, 'Being closely tied to one's ethnic background,' is not a defining aspect of spirituality or religion as it pertains more to cultural identity rather than spiritual beliefs.

5. The healthcare provider is examining a patient who is reporting "feeling cold."? Which is a mechanism of heat loss in the body?

• A. Exercise
• B. Radiation
• C. Metabolism
• D. Food digestion

Correct answer: B

Rationale: When the body needs to lose heat, one of the mechanisms it employs is radiation. Radiation involves the transfer of heat from the body to the environment in the form of infrared waves. While metabolism, exercise, and food digestion contribute to heat production, they are not mechanisms for heat loss. Metabolism generates heat as a byproduct, exercise increases metabolic rate leading to heat production, and food digestion involves some heat generation, but these processes do not directly facilitate heat loss. Therefore, in the scenario where the patient is feeling cold, radiation is the primary mechanism for the body to lose excess heat and maintain a stable internal temperature.

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