Nursing Elites

1. A client is planning to perform nasotracheal suction for a client who has COPD and an artificial airway. Which of the following actions should the nurse take?

• A. Perform suctioning for up to four passes.
• B. Apply suction to the catheter when advancing it into the trachea.
• C. Preoxygenate the client with 100% oxygen for up to 3 min.
• D. Limit each suction pass to 25 seconds.

Correct answer: C

Rationale:

2. A client with chronic obstructive pulmonary disease (COPD) is being assessed by a nurse. Which finding should the nurse expect?

• A. Increased anterior-posterior (AP) chest diameter
• B. Decreased respiratory rate
• C. Weight gain
• D. Productive cough with yellow sputum

Correct answer: A

Rationale: In COPD, the client often develops a barrel chest, characterized by an increased anterior-posterior diameter of the chest. This change is due to air trapping and hyperinflation of the lungs. Decreased respiratory rate, weight gain, and productive cough with yellow sputum are not typically associated with COPD. Weight loss is more common due to increased work of breathing and decreased energy expenditure in individuals with COPD.

3. A client is prescribed prednisone for asthma management. Which statement by the client indicates a need for further teaching?

• A. I will take this medication every day to prevent asthma attacks.
• B. I will avoid people with infections while taking this medication.
• C. I will take this medication with food to prevent stomach upset.
• D. I will stop taking this medication if I feel fine.

Correct answer: D

Rationale: The correct answer is D because prednisone, a corticosteroid, should not be abruptly stopped. It must be tapered off gradually to prevent adrenal insufficiency. Choices A, B, and C demonstrate proper understanding of the medication's use and side effects, emphasizing the importance of daily intake, infection prevention, and taking it with food to avoid stomach upset.

4. A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

• A. Insert an indwelling urinary catheter.
• B. Inspect the mouth for signs of inhalation injuries.
• C. Administer intravenous pain medication.
• D. Draw blood for a complete blood cell (CBC) count.

Correct answer: B

Rationale: When caring for a client with burns, especially burns to the face and chest, the priority action for the nurse is to inspect the mouth for signs of inhalation injuries. Inhalation injuries can be life-threatening and may not be immediately apparent. Identifying these injuries early allows for prompt intervention and can significantly impact the client's outcomes. While other actions such as pain management and blood tests are important, assessing for inhalation injuries takes precedence due to its critical nature.

5. A client had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?

• A. Poor impulse control
• B. Inability to discriminate words and letters
• C. Deficits in the right visual field
• D. Motor retardation

Correct answer: A

Rationale: A stroke affecting the right cerebral hemisphere can lead to poor impulse control due to the involvement of this area in regulating behavior and inhibiting impulses. Deficits in the right visual field are associated with stroke affecting the left cerebral hemisphere. Inability to discriminate words and letters may be seen in left cerebral hemisphere strokes. Motor retardation may be observed with strokes affecting motor areas in either hemisphere but is not the most specific finding related to a right cerebral hemisphere stroke.

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