Nursing Elites

1. A client in the emergency department is experiencing an acute asthma attack. Which assessment indicates an improvement in respiratory status?

• A. SaO2 95%
• B. Wheezing
• C. Retraction of sternal muscles
• D. Premature ventricular complexes (PVC's)

Correct answer: A

Rationale: An SaO2 of 95% indicates an improvement in the client's oxygen saturation, suggesting better respiratory status. In asthma exacerbation, a decrease in SaO2 levels would signal worsening respiratory distress. Wheezing, retraction of sternal muscles, and premature ventricular complexes are indicators of respiratory compromise and worsening respiratory status in acute asthma attacks. Monitoring SaO2 levels is crucial in assessing the effectiveness of interventions and guiding treatment decisions.

2. The physician orders the administration of high-humidity oxygen by face mask and placement of the patient in a high Fowler’s position. After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. Which of the following nursing interventions has the greatest potential for improving this situation?

• A. Encourage the patient to increase her fluid intake to 200 ml every 2 hours
• B. Place a humidifier in the patient’s room
• C. Continue administering oxygen by high humidity face mask
• D. Perform chest physiotherapy on a regular schedule

Correct answer: D

Rationale: Chest physiotherapy is the most effective intervention in cases of impaired gas exchange related to increased secretions. This technique helps mobilize and clear secretions from the airways, thereby improving gas exchange in the lungs. Placing a humidifier or administering oxygen by high humidity face mask may provide moisture but may not directly address the clearance of secretions. Encouraging increased fluid intake can help with hydration but may not address the underlying issue of impaired gas exchange due to secretions.

3. When planning care for a client on mechanical ventilation, which mode of ventilation that increases the effort of the client's respiratory muscles should NOT be included in the plan of care?

• A. Assist-control
• B. Synchronized intermittent mandatory ventilation
• C. Continuous positive airway pressure
• D. Pressure support ventilation

Correct answer: A

Rationale: Assist-control ventilation mode delivers a preset tidal volume at a set rate; however, it may not be suitable for clients who need to maintain some level of respiratory muscle activity. This mode provides full support for each breath, potentially leading to decreased respiratory muscle strength over time. Therefore, it is important to avoid using assist-control mode for clients who require increased effort of respiratory muscles to prevent muscle atrophy and promote optimal respiratory function.

4. When providing mouth care to an unconscious client, what is the best position for the client?

• A. Fowler’s position
• B. Side-lying
• C. Supine
• D. Trendelenburg

Correct answer: B

Rationale: The best position for an unconscious client when providing mouth care is the side-lying position. This position helps prevent aspiration by allowing fluids to drain out of the mouth easily, reducing the risk of choking or aspiration pneumonia. Placing the client in a side-lying position also promotes comfort and safety during the procedure. The other options are not ideal for mouth care in an unconscious client: Fowler’s position may increase the risk of aspiration, the supine position can lead to aspiration as well, and Trendelenburg position is not recommended due to potential adverse effects on blood circulation and increased intracranial pressure.

5. What is the term for the body's ability to defend itself against specific invading agents such as bacteria, toxins, viruses, and foreign bodies?

• A. Hormones
• B. Secretion
• C. Immunity
• D. Glands

Correct answer: C

Rationale: The correct answer is C: Immunity. Immunity refers to the body's ability to protect itself against specific invading agents like bacteria, toxins, viruses, and foreign bodies by recognizing and destroying them. It is a crucial defense mechanism that helps maintain health and prevent infections and diseases. Choices A, B, and D are incorrect because hormones are chemical messengers, secretion is the process of releasing substances, and glands are organs that produce and release substances, none of which specifically relate to the body's defense against invading agents.

Similar Questions