Nursing Elites

1. A client is admitted with a diagnosis of chronic obstructive pulmonary disease (COPD) exacerbation. Which intervention should the nurse implement first?

• A. Administer bronchodilators as prescribed.
• B. Administer oxygen via nasal cannula.
• C. Encourage the client to cough and deep breathe.
• D. Position the client in high Fowler's position.

Correct answer: B

Rationale: Administering oxygen via nasal cannula (B) is the priority intervention for a client with COPD exacerbation to improve oxygenation. In COPD exacerbation, there is impaired gas exchange leading to hypoxemia, making oxygen therapy the initial priority. Administering bronchodilators (A) helps with bronchodilation but should come after ensuring adequate oxygenation. Encouraging coughing and deep breathing (C) and positioning the client in high Fowler's position (D) are also beneficial interventions, but the first step is to address the oxygenation needs of the client.

2. When culturing a wound, the nurse should obtain the sample from which part of the wound?

• A. The outer edges of the wound.
• B. All necrotic sections of the wound.
• C. Areas containing purulent or pooled exudates.
• D. Any particularly painful area of the wound.

Correct answer: C

Rationale: To collect a wound culture, the nurse should first clean the wound to remove skin flora and then insert a sterile swab from a culturette tube into the wound secretions.

3. During evacuation of a group of clients from a medical unit because of a fire, the nurse observes an ambulatory client walking alone toward the stairway at the end of the hall. Which action should the nurse take?

• A. Assign an unlicensed assistive personnel to transport the client via a wheelchair.
• B. Remind the client to walk carefully down the stairs until reaching a lower floor.
• C. Ask the client to help by assisting a wheelchair-bound client to a nearby elevator.
• D. Open the closest fire doors to facilitate the evacuation of ambulatory clients.

Correct answer: B

Rationale: During a fire evacuation, it is crucial for ambulatory clients to be reminded to walk carefully down the stairs. This helps ensure the safety of the client by preventing falls or injuries during the evacuation process. Directing the client to proceed cautiously down the stairs until reaching a lower floor provides necessary guidance to promote a safe evacuation process. Choice A is incorrect because assigning unlicensed assistive personnel to transport the client via a wheelchair may delay the evacuation process and increase the risk of injury. Choice C is incorrect as it distracts the ambulatory client from evacuating safely by involving them in assisting another client. Choice D is incorrect as opening fire doors may not be the most appropriate action at that moment; prioritizing safe evacuation procedures for ambulatory clients is essential.

4. While suctioning a client’s nasopharynx, the nurse observes that the client’s oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. What action should the nurse take in response to this finding?

• A. Complete the intermittent suction of the nasopharynx.
• B. Reposition the pulse oximeter clip to obtain a new reading.
• C. Stop suctioning until the pulse oximeter reading is above 95%.
• D. Apply an oxygen mask over the client’s nose and mouth.

Correct answer: A

Rationale: A stable oxygen saturation reading of 94% indicates that the nurse can continue with the suctioning procedure. It is within an acceptable range, and there is no immediate need to interrupt the procedure. Continuing with the suctioning will help maintain airway patency and promote adequate oxygenation. Choice B is incorrect because repositioning the pulse oximeter clip is unnecessary when the reading is stable. Choice C is incorrect as there is no evidence to support stopping the suctioning procedure solely based on the oxygen saturation reading of 94%. Choice D is not the best action at this point, as applying an oxygen mask is not indicated when the oxygen saturation is stable and within an acceptable range.

5. In taking a client's history, the nurse asks about the stool characteristics. Which description should the nurse report to the health care provider as soon as possible?

• A. Daily black, sticky stool
• B. Daily dark brown stool
• C. Firm brown stool every other day
• D. Soft light brown stool twice a day

Correct answer: A

Rationale: The correct answer is A: Daily black, sticky stool. Black sticky stool (melena) is a sign of gastrointestinal bleeding and should be reported to the health care provider promptly. This finding indicates the presence of digested blood in the stool. Choices B, C, and D describe variations of normal stool color and consistency, which do not raise immediate concerns related to gastrointestinal bleeding.

Similar Questions