Nursing Elites

1. A client with pneumonia is receiving oxygen via nasal cannula at 2 L/min. What assessment finding indicates the need for further intervention?

• A. The client reports feeling short of breath.
• B. The client's oxygen saturation is 92%.
• C. The client's respiratory rate is 20 breaths per minute.
• D. The client is unable to complete sentences without pausing.

Correct answer: D

Rationale: The correct answer is D because the inability to complete sentences without pausing indicates respiratory distress and the need for immediate intervention. This finding suggests an increased work of breathing and inadequate oxygenation. Choices A, B, and C are not as urgent as choice D. Feeling short of breath (choice A) is expected in pneumonia but does not necessarily indicate the need for immediate intervention. An oxygen saturation of 92% (choice B) is slightly below the normal range but may not require immediate intervention. A respiratory rate of 20 breaths per minute (choice C) is within the normal range and does not signify an urgent need for intervention.

2. After a spider bite on the lower extremity, a client is admitted to treat an infection that is spreading up the leg. Which admission assessment findings should the nurse report to the healthcare provider?

• A. Swollen lymph nodes in the groin
• B. Core body temperature of 100.5°F
• C. All of the above
• D. Elevated white blood cell count

Correct answer: C

Rationale: All of the above findings should be reported to the healthcare provider for prompt evaluation and treatment. Swollen lymph nodes in the groin indicate regional lymphatic involvement, a core body temperature of 100.5°F suggests a mild fever response, and an elevated white blood cell count indicates an ongoing infection process. These findings collectively point towards the spread of infection and require immediate attention to prevent further complications.

3. The nurse is administering a new medication to a client. What is the priority action before administering the drug?

• A. Verify the client's allergies
• B. Check the client's blood pressure
• C. Assess the client's pain level
• D. Provide client education on the medication

Correct answer: A

Rationale: Verifying the client's allergies is the priority action before administering any medication. It is crucial to identify any known allergies to prevent potential allergic reactions, which can be severe and life-threatening. Checking the client's blood pressure, assessing pain levels, and providing education on the medication are important aspects of client care but verifying allergies is essential for ensuring the safety of the client.

4. A nurse finds a pregnant client at 33 weeks gestation in cardiac arrest. What modification to cardiopulmonary resuscitation (CPR) should the nurse implement?

• A. Administer chest compressions at a faster rate.
• B. Position a firm wedge under the client’s pelvis and thorax at a 30-degree tilt.
• C. Position the client flat with legs elevated.
• D. Call for immediate assistance and prepare for a cesarean section.

Correct answer: B

Rationale: In a pregnant client at 33 weeks gestation, performing CPR requires tilting the pelvis and thorax at a 30-degree angle to relieve pressure on the vena cava, ensuring proper circulation during compressions. Administering chest compressions at a faster rate (Choice A) may not address the specific needs of a pregnant client in cardiac arrest. Positioning the client flat with legs elevated (Choice C) is not recommended as it can worsen vena cava compression. Calling for immediate assistance and preparing for a cesarean section (Choice D) should be considered only after initiating appropriate CPR modifications.

5. A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge?

• A. Nutritional guidelines to support blood health
• B. Signs of infection to monitor for
• C. When to give pain medication
• D. Instructions about how much fluid the child should drink daily

Correct answer: D

Rationale: Proper hydration is crucial in managing sickle cell anemia (SCA) as it helps prevent sickling of red blood cells and reduces blood viscosity, which can lead to painful crises. Ensuring the child drinks enough fluids is essential to maintain adequate hydration levels and reduce the risk of complications. While nutritional guidelines and recognizing signs of infection are important aspects of care, maintaining proper hydration is the most immediate and critical factor in managing SCA and preventing crises.

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