Nursing Elites

1. A client with AIDS has impaired gas exchange from a respiratory infection. Which assessment finding warrants immediate intervention by the nurse?

• A. Elevated temperature
• B. Generalized weakness
• C. Diminished lung sounds
• D. Pain when swallowing

Correct answer: D

Rationale: In a client with AIDS and impaired gas exchange from a respiratory infection, pain when swallowing can indicate esophageal involvement, such as esophagitis or an esophageal infection like candidiasis. These conditions can significantly impact the client's ability to take in nutrition and medications, leading to complications like dehydration and malnutrition. Therefore, immediate intervention is required to address the underlying cause and prevent further complications. Elevated temperature (choice A) may indicate infection but does not directly address the impaired gas exchange. Generalized weakness (choice B) and diminished lung sounds (choice C) are concerning but do not directly relate to the immediate need for intervention in the context of esophageal involvement in a client with impaired gas exchange.

2. The nurse caring for a hospitalized older client with a left hip fracture as a result of a fall at home notices different assessment findings. Which assessment finding warrants immediate intervention by the nurse?

• A. Pain rated 7/10 on the pain scale.
• B. Mild swelling at the fracture site.
• C. Small amount of bleeding from the surgical site.
• D. Left extremity capillary refill greater than 5 seconds.

Correct answer: D

Rationale: The correct answer is D. A left extremity capillary refill greater than 5 seconds indicates poor blood flow to the extremity, which is a sign of compromised circulation. This finding requires immediate intervention by the nurse to prevent complications such as tissue damage or necrosis. Choices A, B, and C are important assessments but do not indicate an immediate need for intervention like the delayed capillary refill in choice D.

3. What could suddenly occur in a child with acute epiglottitis?

• A. Increased carbon dioxide levels
• B. Airway obstruction
• C. Inability to swallow
• D. Bronchial collapse

Correct answer: B

Rationale: In acute epiglottitis, the infected epiglottis becomes inflamed and can lead to sudden airway obstruction, which is a life-threatening emergency. This can cause difficulty breathing and necessitates immediate intervention to secure the airway. Increased carbon dioxide levels may occur due to inadequate ventilation resulting from airway obstruction, but the primary concern is the obstruction itself, not the carbon dioxide levels. Inability to swallow may be present due to pain and swelling in the throat but is not the immediate life-threatening complication associated with acute epiglottitis. Bronchial collapse is not a typical consequence of acute epiglottitis.

4. When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain?

• A. Daily weight
• B. Vital signs
• C. Level of consciousness
• D. Bowel sounds

Correct answer: A

Rationale: Corrected Rationale: Daily weight is the most important assessment to monitor fluid balance in clients with nephrotic syndrome. In nephrotic syndrome, excessive protein loss leads to fluid retention and edema. Monitoring daily weight allows the nurse to assess fluid status accurately. Vital signs, while important, may not directly reflect fluid balance changes in nephrotic syndrome. Level of consciousness and bowel sounds are not typically the primary assessments for monitoring fluid balance in clients with nephrotic syndrome.

5. The nurse is providing postoperative care for a client who had a thyroidectomy. Which assessment finding requires immediate intervention?

• A. Hoarseness and weak voice
• B. Calcium level of 8.0 mg/dL (2.0 mmol/L)
• C. Heart rate of 110 beats per minute
• D. Difficulty swallowing

Correct answer: D

Rationale: Difficulty swallowing can indicate swelling or hematoma formation, which may compromise the airway and requires immediate intervention. Hoarseness and a weak voice are expected post-thyroidectomy due to manipulation of the laryngeal nerves but do not require immediate intervention. A calcium level of 8.0 mg/dL is within the normal range (8.5-10.5 mg/dL) and may not require immediate intervention. A heart rate of 110 beats per minute may be elevated due to stress or pain postoperatively, but it does not indicate an immediate threat to the airway.

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