Nursing Elites

1. During an acute asthma attack, a healthcare provider assesses a client. Which assessment finding indicates that the client's condition is worsening?

• A. Loud wheezing
• B. Increased respiratory rate
• C. Decreased breath sounds
• D. Productive cough

Correct answer: C

Rationale: In a client experiencing an acute asthma attack, decreased breath sounds suggest severe airway obstruction or respiratory fatigue, indicating a worsening condition. Loud wheezing, increased respiratory rate, and a productive cough are common manifestations during an asthma attack as the airways constrict, leading to turbulent airflow causing wheezing, increased effort to breathe resulting in a higher respiratory rate, and mucus production causing a productive cough. However, decreased breath sounds signify a critical situation requiring immediate intervention.

2. A client with a mediastinal chest tube is being assessed by a nurse. Which symptoms require the nurse's immediate intervention? (SATA)

• A. Production of pink sputum
• B. Tracheal deviation
• C. Pain at insertion site
• D. Sudden onset of shortness of breath

Correct answer: B

Rationale: Immediate intervention is necessary when a client with a mediastinal chest tube exhibits tracheal deviation since it may indicate a tension pneumothorax. This condition requires prompt attention to prevent serious complications. While the production of pink sputum and pain at the insertion site should be monitored and reported, they do not typically require immediate intervention. Sudden onset of shortness of breath could indicate various issues related to the chest tube but is not as critical as tracheal deviation in this context.

3. A nurse working on a cardiac unit delegated taking vital signs to an experienced unlicensed assistive personnel (UAP). Four hours later, the nurse notes the client's blood pressure is much higher than previous readings & the client's mental status has changed. What action by the nurse would most likely have prevented this negative outcome?

• A. Determining if the UAP knew how to take blood pressure
• B. Double-checking the UAP by taking another blood pressure
• C. Providing more appropriate supervision of the UAP
• D. Taking the blood pressure instead of delegating the task

Correct answer: C

Rationale: The most likely action by the nurse that would have prevented the negative outcome is providing more appropriate supervision of the UAP. Supervision is essential in delegation as it involves directing, evaluating, and following up on delegated tasks. By providing adequate supervision, the nurse can ensure that tasks are performed correctly and promptly identify any issues or abnormalities, such as a significant change in vital signs or the client's mental status. This proactive approach can help prevent adverse outcomes and enhance patient safety.

4. A healthcare professional is assessing a client who has a fracture of the femur. Vital signs are obtained on admission and again in 2 hours. Which of the following changes in assessment should indicate to the healthcare professional that the client could be developing a serious complication?

• A. Increased respiratory rate from 18 to 44/min
• B. Increased oral temperature from 36.6� C (97.8� F) to 37� C (98.6� F)
• C. Increased blood pressure from 112/68 to 120/72 mm Hg
• D. Increased heart rate from 68 to 72/min

Correct answer: A

Rationale: An increased respiratory rate from 18 to 44/min is a significant change that should alert the healthcare professional to a potential serious complication. Such a drastic increase in respiratory rate may indicate respiratory distress or hypoxia, which are critical conditions requiring immediate attention. The other options show minor changes in vital signs that are within normal limits and are less likely to indicate a serious complication.

5. A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client findings should the nurse intervene first?

• A. Urticaria
• B. Stridor
• C. Vomiting
• D. Hypotension

Correct answer: B

Rationale:

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