Nursing Elites

1. A client with chronic obstructive pulmonary disease (COPD) is experiencing difficulty breathing. What is the nurse's priority intervention?

• A. Administer a bronchodilator via nebulizer.
• B. Increase the client's oxygen flow rate.
• C. Elevate the head of the bed.
• D. Reposition the client to a side-lying position.

Correct answer: B

Rationale: In clients with COPD experiencing difficulty breathing, increasing the client's oxygen flow rate is the priority intervention. This action helps to improve oxygenation and relieve shortness of breath. While bronchodilators and other medications may be necessary, providing immediate oxygen support is crucial. Elevating the head of the bed and repositioning the client can assist with breathing comfort but do not address the immediate need for improved oxygenation in COPD exacerbation.

2. A client admitted with left-sided heart failure presents with shortness of breath and pink frothy sputum. Which assessment finding requires immediate intervention?

• A. Decreased breath sounds bilaterally.
• B. Heart rate of 110 bpm and irregular rhythm.
• C. Pink frothy sputum and increased respiratory rate.
• D. Elevated blood pressure and shortness of breath.

Correct answer: C

Rationale: Correct Answer: Pink frothy sputum and increased respiratory rate. Pink frothy sputum is a sign of pulmonary edema, indicating fluid in the lungs, a life-threatening condition that requires immediate intervention to prevent respiratory failure. Increased respiratory rate is also concerning as it indicates the body's effort to compensate for the decreased oxygenation. Options A, B, and D are not the most critical findings in this situation. Decreased breath sounds bilaterally may indicate a pneumothorax or atelectasis, heart rate of 110 bpm and irregular rhythm can be managed with medications and further assessment, and elevated blood pressure with shortness of breath is not as urgent as pink frothy sputum and increased respiratory rate.

3. A client with lung cancer is admitted to palliative care. What is the nurse's priority assessment?

• A. Monitor respiratory status and oxygenation.
• B. Evaluate the client's mental status and cognition.
• C. Check the client’s pain level and provide comfort.
• D. Assess the client’s nutritional status and appetite.

Correct answer: A

Rationale: Correct Answer: Monitoring respiratory status and oxygenation is crucial in clients with lung cancer, as metastasis to the lungs or pleural effusion can compromise breathing. This assessment helps in early identification of respiratory distress and the need for interventions to maintain adequate oxygenation. Choice B is important but not the priority in this situation. Evaluating mental status and cognition should follow after ensuring the client's physiological needs are met. Choice C, checking pain level and providing comfort, is essential but secondary to assessing respiratory status. Choice D, assessing nutritional status and appetite, is also important but not the priority when the client's breathing is at risk.

4. The nurse is conducting intake interviews of children at a city clinic. Which child is most susceptible to lead poisoning?

• A. An 8-year-old who lives in a housing project.
• B. A 2-year-old who plays on aging playground equipment.
• C. An adolescent who works in a paint factory.
• D. A 10-year-old with Type 1 diabetes.

Correct answer: B

Rationale: The correct answer is B. Young children, like the 2-year-old playing on aging playground equipment, are at higher risk of lead poisoning due to their hand-to-mouth behavior and exploration of their environment. Aging playground equipment may have lead-based paint that can be ingested by the child. While children living in housing projects are also at risk due to lead-based paint in older buildings, the 2-year-old child playing on potentially lead-contaminated playground equipment is the most susceptible in this scenario. The adolescent working in a paint factory may face occupational hazards related to lead exposure, but the immediate risk from environmental sources is higher for the 2-year-old. Type 1 diabetes in a 10-year-old is not directly linked to an increased susceptibility to lead poisoning.

5. In monitoring tissue perfusion in a client following an above the knee amputation (AKA), which action should the nurse include in the plan of care?

• A. Evaluate closest proximal pulse.
• B. Note amount and color of wound drainage.
• C. Observe for swelling around the stump.
• D. Assess skin elasticity of the stump.

Correct answer: A

Rationale: After an amputation, monitoring the pulse closest to the stump is crucial in evaluating tissue perfusion and the overall health of the limb. Swelling and changes in perfusion can indicate complications such as blood clots or infection. Assessing the proximal pulse helps the nurse ensure adequate blood flow to the remaining limb, thereby preventing further complications. Choices B, C, and D are less directly related to monitoring tissue perfusion in this scenario and are more focused on wound healing and stump care.

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