Nursing Elites

1. A client who is unstable and requires frequent vital signs has an electronic blood pressure machine automatically measuring his blood pressure every 15 min. However, the machine is reading the client’s blood pressure at more frequent intervals, and the readings are not similar. The nurse checks the machine settings and observes the additional readings, but the problem continues. Which of the following is the appropriate nursing action?

• A. Notify the manufacturer
• B. Disconnect the machine, and measure the blood pressure manually every 15 min
• C. Adjust the machine settings again
• D. Ignore the extra readings

Correct answer: B

Rationale: The correct action in this scenario is to disconnect the electronic blood pressure machine and measure the client's blood pressure manually every 15 minutes. Given that the machine is malfunctioning and providing inconsistent readings, relying on manual measurements ensures accuracy and maintains the quality of care. Notifying the manufacturer (Choice A) may be necessary in the long run, but the immediate concern is the accuracy of the vital signs. Adjusting the machine settings again (Choice C) without resolving the underlying issue would not address the problem. Ignoring the extra readings (Choice D) could lead to incorrect assessment and compromise patient care. Therefore, the best course of action is to disconnect the machine and opt for manual blood pressure measurements until the issue is resolved.

2. A client with a history of chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 liters per minute via nasal cannula. The client is short of breath and has a pulse oximetry reading of 88%. What action should the LPN take first?

• A. Increase the oxygen flow rate to 4 liters per minute.
• B. Reposition the client to a high Fowler's position.
• C. Notify the healthcare provider of the client's condition.
• D. Encourage the client to use pursed-lip breathing.

Correct answer: B

Rationale: Repositioning the client to a high Fowler's position should be the first action taken by the LPN. This position helps improve oxygenation by maximizing lung expansion, making it easier for the client to breathe. Increasing the oxygen flow rate without addressing positioning may not fully optimize oxygen delivery. Notifying the healthcare provider should come after immediate interventions. Encouraging pursed-lip breathing is beneficial but should follow the initial positioning to further assist the client in managing their breathing difficulty.

3. A nurse is in a public building when someone cries out, 'Help! I think he is having a heart attack!' The nurse responds to the scene and finds the unconscious adult lying on the floor. Another bystander has obtained an AED. The nurse's first action, after ensuring someone has called for EMS, should be to:

• A. Administer cardiac compressions
• B. Attach the AED pads to the client
• C. Check for a pulse
• D. Perform rescue breaths

Correct answer: A

Rationale: In a scenario where a person is unconscious and there is an indication of a possible heart attack, the immediate priority for the nurse should be to administer cardiac compressions. This action helps maintain circulation and ensures oxygenated blood reaches vital organs until the AED is available. Checking for a pulse or performing rescue breaths may delay essential circulation support, and attaching AED pads should follow the initial step of administering compressions to maximize the chances of a successful resuscitation.

4. A healthcare provider in an office is preparing to auscultate and percuss a client’s thorax as part of a comprehensive physical examination. Which of the following findings should the provider expect?

• A. Rhonchi
• B. Crackles
• C. Resonance
• D. Tactile fremitus

Correct answer: C

Rationale: During a thoracic examination, normal findings should include resonance, which is the expected sound when percussing the thorax. Resonance indicates healthy lung tissue and air-filled spaces. Abnormal findings such as rhonchi and crackles suggest issues like lung congestion or inflammation. Tactile fremitus refers to vibrations felt on the chest wall during palpation and is not typically assessed during percussion and auscultation of the thorax.

5. Which assessment data reflects the need for nurses to include the problem, “Risk for falls,” in a client’s plan of care?

• A. Recent serum hemoglobin level of 16 g/dL
• B. Opioid analgesic received one hour ago
• C. Stooped posture with an unsteady gait
• D. Expressed feelings of depression

Correct answer: B

Rationale: The correct answer is B. The recent administration of opioid analgesics increases the risk for falls due to potential side effects such as sedation and dizziness. Choice A, a recent serum hemoglobin level of 16 g/dL, is not directly related to the risk for falls. Choice C, stooped posture with an unsteady gait, may indicate an existing risk but does not directly reflect the need to include 'Risk for falls' in the care plan. Choice D, expressed feelings of depression, is important to address but is not directly associated with the risk for falls.

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