Nursing Elites

1. A nurse in a provider's office is assessing a client. Which of the following findings is not a manifestation of pulmonary tuberculosis?

• A. Night sweats
• B. Low-grade fever
• C. Weight gain
• D. Blood in the sputum

Correct answer: C

Rationale:

2. A healthcare professional assesses a client's respiratory status. Which information is of highest priority for the healthcare professional to obtain?

• A. Average daily fluid intake
• B. Neck circumference
• C. Height & weight
• D. Occupation & hobbies

Correct answer: D

Rationale: Obtaining information about a client's occupation and hobbies is crucial when assessing respiratory status as many respiratory problems can result from chronic exposure to inhalation irritants related to these activities. Understanding the client's potential exposure can help the healthcare professional identify risk factors and provide appropriate interventions to promote respiratory health.

3. A client has returned from the surgical suite following surgery for a fractured mandible with intermaxillary fixation. Which of the following actions is the priority for the nurse to take?

• A. Prevent aspiration.
• B. Ensure adequate nutrition.
• C. Promote oral hygiene.
• D. Relieve the client's pain.

Correct answer: A

Rationale: Preventing aspiration is the priority for a client with intermaxillary fixation following mandibular surgery. Aspiration can occur due to difficulty swallowing or improper positioning, posing a serious risk to the client's respiratory status. It is crucial for the nurse to ensure that the client's airway is clear and that they are positioned correctly to prevent any potential aspiration events.

4. 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.

5. A client develops a pulmonary embolism. Which of the following interventions should the nurse implement first?

• A. Give morphine IV.
• B. Administer oxygen therapy.
• C. Start an IV infusion of lactated Ringer's.
• D. Initiate cardiac monitoring.

Correct answer: B

Rationale: Administering oxygen therapy is the priority intervention for a client with a pulmonary embolism. Oxygen helps improve oxygenation levels and decrease the workload on the heart. It is crucial to ensure adequate oxygenation before other interventions are initiated. Morphine IV, starting an IV infusion of lactated Ringer's, and initiating cardiac monitoring are important interventions but come after ensuring adequate oxygenation.

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