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. During an assessment of the respiratory pattern of an older adult client receiving end-of-life care, which of the following assessment findings should the nurse identify as Cheyne-Stokes respirations?

• A. Breathing ranging from very deep to very shallow with periods of apnea
• B. Shallow to normal breaths alternating with periods of apnea
• C. Rapid respirations that are unusually deep and regular
• D. An inability to breathe without dyspnea unless sitting upright

Correct answer: A

Rationale: Cheyne-Stokes respirations are characterized by a pattern of breathing that ranges from very deep to very shallow with periods of apnea (temporary cessation of breathing). This pattern is often seen in clients near the end of life or with certain medical conditions affecting the respiratory control center in the brain. The alternating deep and shallow breaths can be distressing for both the client and caregivers. It is crucial for the nurse to recognize this pattern to provide appropriate care and support to the client and their family during this challenging time.

3. A healthcare professional is assessing a client who has a new onset of confusion. Which laboratory value should the professional check first?

• A. Blood glucose level
• B. Serum sodium level
• C. Serum calcium level
• D. Blood urea nitrogen (BUN)

Correct answer: A

Rationale: In a client presenting with a new onset of confusion, checking the blood glucose level first is crucial as hypoglycemia can cause confusion and is easily correctable. Addressing hypoglycemia promptly is essential to prevent further complications.

4. A client who experienced a femur fracture 8 hr ago now reports sudden onset dyspnea and severe chest pain. Which of the following actions should the nurse take first?

• A. Provide high-flow oxygen.
• B. Check the client for a positive Chvostek's sign.
• C. Administer an IV vasopressor medication.
• D. Monitor the client for headache.

Correct answer: A

Rationale: In this situation, the priority action is to provide high-flow oxygen to the client. Sudden onset dyspnea and severe chest pain can be indicative of a pulmonary embolism, which is a life-threatening emergency. Oxygen therapy helps improve oxygenation and stabilizes the client's condition. Checking for Chvostek's sign, administering IV vasopressors, or monitoring for a headache are not the immediate priorities in this critical situation.

5. While caring for a client who was injured in a motor-vehicle crash and reports dyspnea and severe pain, a nurse in the emergency department notes that the client's chest moves inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following?

• A. Atelectasis
• B. Flail chest
• C. Hemothorax
• D. Pneumothorax

Correct answer: B

Rationale: Flail chest is characterized by paradoxical chest movement, where the chest moves inward during inspiration and bulges out during expiration. This occurs due to multiple rib fractures causing a segment of the chest wall to move independently from the rest of the thorax. Atelectasis refers to collapsed lung tissue, hemothorax is blood in the pleural space, and pneumothorax is air in the pleural space. In this scenario, the client's presentation aligns with the characteristic findings of flail chest.

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