Nursing Elites

1. A client with chronic obstructive pulmonary disease (COPD) appears thin and disheveled. Which question should the nurse ask first?

• A. Do you have a strong support system?
• B. What do you understand about your disease?
• C. Do you experience shortness of breath with basic activities?
• D. What medications are you prescribed to take each day?

Correct answer: C

Rationale: In clients with severe COPD, shortness of breath can significantly impact their ability to perform basic activities like bathing and eating. Therefore, the nurse's priority should be to assess if shortness of breath is interfering with the client's basic activities, which can provide crucial information for planning and managing care.

2. A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The facility has 24-hour catheterization laboratory capabilities. To meet The Joint Commission's Core Measures set, by what time should the client have a percutaneous coronary intervention performed?

• A. 1530 (3:30 PM)
• B. 1600 (4:00 PM)
• C. 1630 (4:30 PM)
• D. 1700 (5:00 PM)

Correct answer: C

Rationale: The Joint Commission's Core Measures set for MI includes percutaneous coronary intervention within 90 minutes of the diagnosis of myocardial infarction. Since the client presented at 1500 (3:00 PM), the percutaneous coronary intervention should be performed no later than 1630 (4:30 PM), to adhere to the 90-minute timeline for optimal outcomes.

3. A healthcare provider suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which of the following should be the healthcare provider's priority intervention?

• A. Insert an IV line
• B. Count the respiratory rate
• C. Administer oxygen
• D. Prepare equipment for intubation

Correct answer: B

Rationale: When suspecting anaphylaxis, the priority intervention is to assess the client's respiratory status by counting the respiratory rate. Respiratory distress is a hallmark sign of anaphylaxis, and prompt recognition and management are crucial. Administering oxygen may be necessary, but assessing the respiratory rate takes precedence to determine the severity of the reaction and the need for immediate intervention. Inserting an IV line and preparing for intubation are important interventions in managing anaphylaxis but are secondary to ensuring adequate ventilation.

4. A client has a chest tube in place connected to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded?

• A. Oxygen saturation of 95%
• B. No fluctuations in the water seal chamber
• C. No reports of pleuritic chest pain
• D. Occasional bubbling in the water-seal chamber

Correct answer: B

Rationale: The absence of fluctuations in the water seal chamber indicates that the client's lung has re-expanded. This finding suggests that the negative pressure in the pleural space is restored, preventing air from entering the system. Oxygen saturation, absence of pleuritic chest pain, and occasional bubbling in the water-seal chamber are important assessments but do not specifically indicate lung re-expansion.

5. The trauma unit nurse has received a report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?

• A. Evaluate chest expansion.
• B. Check pupillary response to light.
• C. Assess the capillary refill.
• D. Check the client's response to questions about place and time.

Correct answer: A

Rationale: In a client with multiple injuries following a motor vehicle crash, the priority is to assess for any compromised airway or breathing. Evaluating chest expansion helps the nurse determine if the client is having any difficulty breathing, which is essential for immediate intervention to maintain adequate oxygenation. Checking pupillary response, assessing capillary refill, and checking the client's orientation to place and time are important assessments but are of lower priority compared to ensuring the client's airway and breathing are intact.

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