Nursing Elites

1. A client has a pulmonary embolism & is started on oxygen. The student nurse asks why the client's oxygen saturation has not significantly improved. What response by the nurse is best?

• A. Breathing so rapidly interferes with oxygenation.
• B. Maybe the client has respiratory distress syndrome.
• C. The blood clot interferes with perfusion in the lungs.
• D. The client needs immediate intubation & mechanical ventilation.

Correct answer: C

Rationale: A large blood clot in the lungs will significantly impair gas exchange & oxygenation. Unless the clot is dissolved, this process will continue unabated.

2. A client is unconscious with a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?

• A. Kussmaul respirations
• B. Apneustic respirations
• C. Cheyne-Stokes respirations
• D. Stridor

Correct answer: C

Rationale: Cheyne-Stokes respirations are characterized by periods of deep, rapid breathing followed by periods of apnea. This pattern is often seen in clients with neurological or cardiac conditions. Kussmaul respirations are deep and rapid breaths often associated with metabolic acidosis. Apneustic respirations are characterized by prolonged inhalations with shortened exhalations and can indicate damage to the pons. Stridor is a high-pitched, noisy respiratory sound usually associated with upper airway obstruction. Therefore, in this scenario, the client's alternating pattern of hyperventilation and apnea aligns with Cheyne-Stokes respirations.

3. A client with COPD is developing a plan of care. Which of the following interventions should the nurse include in the plan?

• A. Restrict the client's fluid intake to less than 2 L/day
• B. Provide the client with a low-protein diet
• C. Have the client use the early-morning hours for exercise and activity
• D. Instruct the client to use pursed-lip breathing

Correct answer: D

Rationale: In COPD, pursed-lip breathing helps improve breathing efficiency by maintaining positive pressure in the airways, preventing airway collapse, and promoting oxygenation. This technique assists in controlling respiratory rate, reducing dyspnea, and enhancing oxygen saturation levels. Restricting fluid intake is not typically a part of COPD management. Providing a low-protein diet is not a standard intervention for COPD. Early-morning hours are generally not recommended for exercise due to cooler temperatures and higher pollution levels, which can exacerbate COPD symptoms.

4. When caring for a client with acute pancreatitis, what intervention is most appropriate?

• A. Encourage a high-protein diet.
• B. Administer pain medication as needed.
• C. Provide small, frequent meals.
• D. Increase oral fluid intake.

Correct answer: B

Rationale: Administering pain medication as needed is the most appropriate intervention for a client with acute pancreatitis. Pain management is crucial as pancreatitis can cause severe and debilitating pain. Providing pain relief is essential to improve the client's comfort and well-being.

5. A client with newly diagnosed osteoporosis is being taught about lifestyle modifications. Which instruction should be included?

• A. Increase intake of caffeinated beverages.
• B. Engage in weight-bearing exercises regularly.
• C. Avoid exposure to sunlight.
• D. Take calcium supplements with iron.

Correct answer: B

Rationale: Engaging in weight-bearing exercises is crucial for individuals with osteoporosis as it helps strengthen bones and reduce the risk of fractures. Weight-bearing exercises include activities like walking, jogging, dancing, and strength training. These exercises help improve bone density and overall bone health, making them an essential component of lifestyle modifications for individuals with osteoporosis.

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