Nursing Elites

1. A client with chronic obstructive pulmonary disease (COPD) is admitted with increasing shortness of breath. What is the nurse's priority action?

• A. Administer oxygen via nasal cannula.
• B. Reposition the client to improve breathing.
• C. Perform chest physiotherapy.
• D. Encourage the client to cough and deep breathe.

Correct answer: A

Rationale: The correct answer is A: Administer oxygen via nasal cannula. Oxygen therapy is the priority intervention for a client with COPD experiencing increasing shortness of breath. It helps improve oxygenation and relieve respiratory distress. Choice B is not the priority as oxygenation needs to be addressed first. Choice C, chest physiotherapy, may be beneficial but is not the immediate priority in this situation. Choice D, encouraging the client to cough and deep breathe, is not the priority intervention when oxygenation is compromised.

2. A client has suspected compartment syndrome of the right lower leg. What is the nurse’s priority intervention?

• A. Elevate the right leg to reduce swelling.
• B. Loosen any restrictive dressings on the leg.
• C. Prepare the client for emergency surgery.
• D. Administer pain medication as prescribed.

Correct answer: B

Rationale: In a suspected case of compartment syndrome, the nurse's priority intervention is to loosen any restrictive dressings on the leg. This action helps to relieve pressure within the affected compartment, improve circulation, and prevent permanent damage. Elevating the leg may further increase pressure, preparing for emergency surgery is premature without proper assessment and diagnosis, and administering pain medication should come after addressing the primary issue of relieving pressure.

3. An older male client, who is a retired chef, is hospitalized with a diabetic ulcer on his foot. His daughter tells the nurse that her father has become increasingly obsessed with the way his food is prepared in the hospital. The nurse's response should be based on what information?

• A. His daughter's observations suggest the client is depressed
• B. His compulsiveness about food may indicate new cognitive decline
• C. Obsessiveness with food is common in diabetic clients
• D. If the client was compulsive about food when he was younger, the aging process can magnify this

Correct answer: D

Rationale: Age can magnify pre-existing compulsive tendencies. If the client was detail-oriented about food earlier in life, this behavior may intensify with aging. It's important to acknowledge and address the client's concerns respectfully. Choices A, B, and C are incorrect because the daughter's observations do not necessarily point to depression, the compulsiveness about food does not indicate new cognitive decline without further assessment, and obsessiveness with food is not specifically common in diabetic clients.

4. A client with pneumonia is receiving oxygen therapy. What assessment finding requires immediate intervention?

• A. Increased oxygen saturation of 96%.
• B. Oxygen saturation of 89%.
• C. Respiratory rate of 20 breaths per minute.
• D. Decreased heart rate of 70 beats per minute.

Correct answer: B

Rationale: The correct answer is B. An oxygen saturation of 89% indicates hypoxemia, which is below the normal range (usually 95-100%). This finding requires immediate intervention as it signifies inadequate oxygenation. Options A, C, and D are within normal limits and do not indicate an urgent need for intervention. Option A indicates a good oxygen saturation level, option C denotes a normal respiratory rate, and option D suggests a normal heart rate. Therefore, these options do not require immediate intervention compared to the critically low oxygen saturation level of 89% in option B.

5. A client with chronic renal failure has a potassium level of 6.5 mEq/L. What is the nurse's priority action?

• A. Administer a potassium supplement.
• B. Notify the healthcare provider immediately.
• C. Administer calcium gluconate.
• D. Restrict the client's potassium intake.

Correct answer: B

Rationale: A potassium level of 6.5 mEq/L indicates hyperkalemia, which can lead to life-threatening arrhythmias. The correct priority action for the nurse is to notify the healthcare provider immediately. Hyperkalemia requires prompt intervention to lower potassium levels and prevent complications. Administering a potassium supplement (Choice A) would worsen the condition. Administering calcium gluconate (Choice C) is a treatment option but is not the nurse's priority action. Restricting the client's potassium intake (Choice D) may be necessary but is not the immediate priority when facing a critical potassium level.

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