Nursing Elites

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

• A. Productive cough with yellow sputum.
• B. Oxygen saturation of 88%.
• C. Respiratory rate of 20 breaths per minute.
• D. Heart rate of 90 beats per minute.

Correct answer: B

Rationale: An oxygen saturation of 88% indicates hypoxemia, which is a critical condition requiring immediate intervention to improve oxygenation. Hypoxemia can lead to tissue hypoxia and further complications. A productive cough with yellow sputum is common in pneumonia but may not require immediate intervention unless it worsens or is associated with other concerning symptoms. A respiratory rate of 20 breaths per minute is within the normal range, indicating adequate ventilation. A heart rate of 90 beats per minute is also within a normal range and may not require immediate intervention unless it is accompanied by other abnormal findings.

2. An antibiotic IM injection for a 2-year-old child is ordered. The total volume of the injection equals 2.0 ml. The correct action is to

• A. Administer the medication in 2 separate injections
• B. Give the medication in the dorsal gluteal site
• C. Call to get a smaller volume ordered
• D. Check with the pharmacy for a liquid form of the medication

Correct answer: A

Rationale: Injections over 1 mL should be split into two separate injections for young children. This helps in preventing discomfort, ensuring proper absorption, and reducing the risk of tissue damage. Giving the medication in one injection of 2.0 ml might be too much for a 2-year-old child. Choices B and D are incorrect because the dorsal gluteal site is not recommended for children due to potential injury, and changing the form of medication might not be necessary if the volume can be adjusted. Choice C is unnecessary as splitting the dose into two injections is the appropriate action.

3. A client with chronic obstructive pulmonary disease (COPD) is being discharged home. What should the nurse include in the discharge teaching?

• A. Limit fluid intake to prevent lung congestion
• B. Avoid all physical activity to conserve energy
• C. Perform pursed-lip breathing during activities
• D. Increase oxygen flow rate if shortness of breath occurs

Correct answer: C

Rationale: The correct answer is C. Pursed-lip breathing helps control breathing and improves oxygen exchange in clients with COPD. It can ease shortness of breath during activities and should be included in discharge teaching to manage symptoms. Option A is incorrect as adequate fluid intake is important for thinning mucus in COPD. Option B is wrong as physical activity, as tolerated, is beneficial for COPD patients. Option D is also incorrect because changing oxygen flow rate without healthcare provider guidance can be dangerous.

4. A client with a history of hypertension and hyperlipidemia is admitted with chest pain. What is the nurse's priority action?

• A. Administer prescribed nitroglycerin.
• B. Obtain a 12-lead electrocardiogram (ECG).
• C. Check the client's vital signs.
• D. Place the client on continuous telemetry.

Correct answer: B

Rationale: The correct answer is to obtain a 12-lead electrocardiogram (ECG). This action is crucial in assessing the heart's electrical activity and helps in the evaluation of chest pain. Administering nitroglycerin (Choice A) may be necessary but should come after obtaining the ECG to confirm the diagnosis. Checking vital signs (Choice C) is important but does not provide direct information about the heart's electrical status. Placing the client on continuous telemetry (Choice D) may be appropriate later but does not provide immediate information on the heart's electrical activity as an ECG does.

5. A client is receiving a blood transfusion and develops chills and back pain. What is the nurse's first action?

• A. Stop the transfusion and notify the healthcare provider.
• B. Monitor the client's vital signs every 15 minutes.
• C. Administer a PRN dose of diphenhydramine.
• D. Prepare to administer an antihistamine.

Correct answer: A

Rationale: The correct first action for the nurse is to stop the transfusion and notify the healthcare provider. These symptoms suggest a transfusion reaction, and stopping the transfusion is crucial to prevent further complications. Notifying the healthcare provider ensures timely intervention and appropriate management for the client's condition. Monitoring vital signs, administering diphenhydramine, or preparing to administer an antihistamine can be considered after stopping the transfusion and seeking guidance from the healthcare provider. However, the immediate priority is to halt the transfusion and inform the provider.

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