Nursing Elites

1. A healthcare professional auscultates a harsh hollow sound over a client's trachea & larynx. Which action should the healthcare professional take first?

• A. Document findings.
• B. Administer O2 therapy.
• C. Position client in high-Fowler's position.
• D. Administer prescribed albuterol.

Correct answer: A

Rationale: The healthcare professional has identified bronchial breath sounds, which are normal findings over the trachea & larynx, characterized by harsh, hollow, tubular, and blowing sounds. The appropriate initial action for the healthcare professional is to document these normal findings. Oxygen therapy, administering albuterol, or repositioning the client is unnecessary as this finding does not indicate a need for intervention.

2. A client who is interested in smoking cessation receives teaching from a nurse. Which statements should the nurse include in this teaching? (Select ONE that does not apply)

• A. Find an activity that you enjoy and that will keep your hands busy.
• B. Keep healthy snacks on hand to nibble on.
• C. Identify reasons for quitting smoking.
• D. Make a list of reasons for quitting smoking.

Correct answer: C

Rationale: When teaching a client interested in smoking cessation, the nurse should include advice to find an activity that keeps hands busy to help distract from smoking urges, keep healthy snacks on hand to manage oral cravings, and drink at least 8 glasses of water daily to aid in flushing out toxins. Making a list of reasons for quitting smoking is also beneficial to reinforce motivation. It is important to avoid punitive measures or punishments for relapses as this can negatively impact the client's progress.

3. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. Which assessment finding requires the nurse to take immediate action?

• A. Oxygen saturation of 90%
• B. Respiratory rate of 22 breaths per minute
• C. Client reports shortness of breath
• D. Client's respiratory rate decreases to 10 breaths per minute

Correct answer: D

Rationale: A decrease in the client's respiratory rate to 10 breaths per minute, while receiving oxygen therapy for COPD, is a concerning finding that may indicate carbon dioxide retention and respiratory depression. This situation requires immediate action to prevent further complications. An oxygen saturation of 90% is within an acceptable range for COPD patients on oxygen therapy. A respiratory rate of 22 breaths per minute and reports of shortness of breath are common in clients with COPD and may not necessitate immediate action unless accompanied by other concerning symptoms.

4. A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse's priority?

• A. Increase the oxygen flow to 3 L/min.
• B. Assess the client's respiratory status.
• C. Call emergency services for the client.
• D. Have the client cough and expectorate secretions.

Correct answer: B

Rationale: When a client with COPD on oxygen therapy reports difficulty breathing, the priority action for the nurse is to assess the client's respiratory status. This involves evaluating the client's oxygen saturation levels, respiratory rate, effort of breathing, lung sounds, and overall respiratory distress. By assessing the client's respiratory status, the nurse can determine the severity of the situation and make appropriate decisions regarding further interventions, such as adjusting oxygen flow rate, providing respiratory treatments, or seeking emergency assistance if necessary.

5. While dining at a restaurant, a person begins to choke. Which of the following actions should the nurse take?

• A. Instruct the person to call 911.
• B. Ask the person if he/she can speak.
• C. Use the jaw-thrust maneuver.
• D. Perform abdominal thrusts.

Correct answer: B

Rationale: When encountering a choking individual, the nurse should first assess the person's ability to speak. If the person can speak, it indicates that their airway is partially obstructed, allowing some air to pass. In this case, encouraging the person to continue coughing and monitoring them closely may be appropriate. If the person cannot speak, it may suggest a complete airway obstruction and immediate intervention is required. Instructing the person to call 911 (Choice A) may be necessary if the situation worsens. Using the jaw-thrust maneuver (Choice C) is not appropriate for a choking victim. Performing abdominal thrusts (Choice D) is typically recommended for conscious choking victims, not chest compressions.

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