Nursing Elites

1. A client with chronic obstructive pulmonary disease (COPD) receives oxygen therapy. Which finding requires immediate intervention by the nurse?

• A. Oxygen saturation of 91%
• B. Respiratory rate of 10 breaths per minute
• C. Client reports shortness of breath
• D. Use of accessory muscles

Correct answer: B

Rationale: A respiratory rate of 10 breaths per minute in a client with COPD receiving oxygen therapy may indicate respiratory depression, necessitating immediate intervention. An oxygen saturation of 91%, client reports of shortness of breath, and use of accessory muscles are expected in COPD clients.

2. A client learns about pursed-lip breathing. Which statement by the client indicates teaching has been effective?

• A. I will breathe in quickly through my mouth and out through my nose.
• B. I will breathe in slowly through my nose and out through pursed lips.
• C. I will hold my breath for 10 seconds before exhaling.
• D. I will breathe in and out through pursed lips.

Correct answer: B

Rationale: The correct technique for pursed-lip breathing involves inhaling slowly through the nose and exhaling slowly through pursed lips. This technique helps improve expiration and reduce air trapping. Breathing in quickly, holding the breath, or breathing in and out through pursed lips does not align with the correct method of pursed-lip breathing.

3. In an emergency department, a healthcare provider is preparing to care for a client with multiple system trauma following a motor vehicle crash. What should be the priority focus of care?

• A. Airway protection
• B. Decreasing intracranial pressure
• C. Stabilizing cardiac arrhythmias
• D. Preventing musculoskeletal disability

Correct answer: A

Rationale: In a client with multiple system trauma, airway protection is the priority focus of care. Ensuring a patent airway is crucial for oxygenation and ventilation, which are essential for maintaining vital functions. Without a clear airway, the client's oxygenation and ventilation could be compromised, leading to severe consequences. While decreasing intracranial pressure, stabilizing cardiac arrhythmias, and preventing musculoskeletal disability are important aspects of care, ensuring airway protection takes precedence in this emergency situation.

4. A client had an evacuation of a subdural hematoma. Which of the following actions should the nurse take first?

• A. Observe for cerebrospinal fluid (CSF) leaks from the evacuation site.
• B. Assess for an increase in temperature.
• C. Check the oximeter.
• D. Monitor for manifestations of increased intracranial pressure.

Correct answer: C

Rationale: When caring for a client who had an evacuation of a subdural hematoma, the nurse's priority is to check the oximeter. Monitoring oxygen saturation is crucial to ensure adequate tissue oxygenation, especially after such a procedure. This assessment helps in early detection of hypoxemia, which can be detrimental to the client's recovery. While observing for CSF leaks, assessing for temperature changes, and monitoring for signs of increased intracranial pressure are important, checking the oximeter takes precedence to address immediate oxygenation needs.

5. A client is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic testing reveals the client has an alteration in the gene CYP2C19. What action by the nurse is best?

• A. Instruct the client to eliminate all vitamin K from the diet.
• B. Prepare preoperative teaching for an inferior vena cava (IVC) filter.
• C. Refer the client to a chronic illness support group.
• D. Teach the client to use a soft-bristled toothbrush.

Correct answer: B

Rationale: Clients with an alteration in the CYP2C19 gene do not metabolize warfarin (Coumadin) well, leading to higher blood levels and more side effects. As this client is a poor candidate for warfarin therapy, the prescriber will most likely recommend the implantation of an inferior vena cava (IVC) filter. This device helps prevent blood clots from reaching the lungs, reducing the risk of pulmonary embolism.

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