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. A client with atrial fibrillation is prescribed warfarin, and their INR is elevated. What is the nurse's priority action?

• A. Administer a dose of vitamin K to reverse the effects of warfarin.
• B. Monitor the client for signs of bleeding, such as bruising or nosebleeds.
• C. Increase the client’s warfarin dosage to prevent clot formation.
• D. Notify the healthcare provider immediately and hold the next dose of warfarin.

Correct answer: D

Rationale: An elevated INR in clients taking warfarin increases the risk of bleeding, indicating the dose may be too high. The nurse's priority action is to notify the healthcare provider immediately and hold the next dose of warfarin to prevent bleeding complications. Administering vitamin K is not the first-line intervention for an elevated INR. Monitoring for signs of bleeding is important but not the priority over contacting the healthcare provider. Increasing the warfarin dosage can exacerbate the risk of bleeding and is contraindicated.

3. An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediate follow-up?

• A. Increased appetite
• B. Describes life without purpose
• C. Exhibits mood swings
• D. Complains of insomnia

Correct answer: B

Rationale: An adolescent expressing 'life without purpose' after taking duloxetine (Cymbalta) may be indicating suicidal ideation, which requires immediate attention. The initial period of antidepressant treatment can increase the risk of suicidal thoughts, especially in younger populations. Increased appetite (Choice A) is a common side effect of duloxetine and may not require immediate follow-up. Mood swings (Choice C) and insomnia (Choice D) are also possible side effects of the medication but are not as urgent as addressing suicidal ideation.

4. A client receiving IV heparin reports tarry stools and abdominal pain. What interventions should the nurse implement?

• A. Prepare to administer warfarin.
• B. Assess the characteristics of the client's pain.
• C. Obtain recent partial thromboplastin time results.
• D. Monitor stool for the presence of blood.

Correct answer: D

Rationale: The correct intervention for the client receiving IV heparin who reports tarry stools and abdominal pain is to monitor the stool for the presence of blood. This is crucial to assess for gastrointestinal bleeding, a potential complication of heparin therapy. Assessing the characteristics of the client's pain may be helpful but is not the priority when signs of GI bleeding are present. Administering warfarin is not appropriate without a thorough assessment and confirmation of the cause of symptoms. While obtaining recent partial thromboplastin time results is important in monitoring heparin therapy, in this scenario, the immediate concern is to assess for possible GI bleeding.

5. A client with pneumonia is receiving intravenous (IV) antibiotics. Which assessment finding indicates that the client's condition is improving?

• A. Client's respiratory rate decreases from 24 to 20 breaths per minute
• B. White blood cell count decreases to normal range
• C. Client reports increased energy levels
• D. Cough becomes productive with green sputum

Correct answer: B

Rationale: A decrease in white blood cell count indicates that the infection is responding to treatment and the client's condition is improving. Monitoring the white blood cell count is a more objective indicator of the body's response to the antibiotics. Choices A, C, and D may also be positive signs, but they are less specific and may vary among individuals. Respiratory rate alone may not be sufficient to indicate improvement, as other factors can influence it. Energy levels and cough characteristics are subjective and may not always correlate with the effectiveness of antibiotic treatment.

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