Nursing Elites

1. 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.

2. A client is 12 hours postoperative following colon resection. Which of the following interventions should the nurse include in the plan to reduce respiratory complications?

• A. Use incentive spirometer every 4 hours while awake.
• B. Initiate ambulation after discontinuing the NG tube.
• C. Maintain a supine position with an abdominal binder.
• D. Splint the incision to support coughing every 2 hours.

Correct answer: D

Rationale: Following a colon resection surgery, it is essential to support the incision site to reduce the risk of respiratory complications. Splinting the incision helps to minimize pain during coughing, aiding in effective clearing of secretions and preventing respiratory problems. This intervention supports the client's respiratory function postoperatively, promoting optimal recovery.

3. What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP) for a client receiving O2 at 4 liters per nasal cannula?

• A. Apply water-soluble ointment to nares and lips.
• B. Periodically adjust the oxygen flow rate.
• C. Remove the tubing from the client's nose.
• D. Turn the client every 2 hours or as needed.

Correct answer: A

Rationale: When a client is receiving oxygen at a high flow rate, it can cause drying of the nasal passages and lips. Therefore, a comfort measure that can be delegated to unlicensed assistive personnel (UAP) is applying water-soluble ointment to the client's nares and lips. Adjusting the oxygen flow rate should be done by licensed nursing staff, not UAP. Removing the tubing can disrupt the oxygen delivery and should be performed by trained personnel. Turning the client every 2 hours is a general comfort measure but is not specific to addressing the drying effects of oxygen therapy.

4. A client in an emergency department has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?

• A. Raise the foot of the bed to a 90� angle
• B. Remove the dressing to inspect the wound
• C. Prepare to insert a central line
• D. Administer oxygen via nasal cannula

Correct answer: D

Rationale: In a client with a sucking chest wound, the priority is to administer oxygen via nasal cannula to improve oxygenation. The client's blood pressure, weak pulse rate, and elevated respiratory rate indicate hypovolemic shock, so increasing oxygen supply is crucial. Raising the foot of the bed, removing the dressing, or preparing to insert a central line are not immediate actions needed for a client with a sucking chest wound and signs of shock.

5. During an admission assessment of a client with COPD and emphysema complaining of a frequent productive cough and shortness of breath, what assessment finding should the nurse anticipate?

• A. Respiratory alkalosis
• B. Increased anteroposterior diameter of the chest
• C. Oxygen saturation level 96%
• D. Petechiae on chest

Correct answer: B

Rationale: COPD and emphysema are chronic respiratory conditions that can lead to changes in the shape of the chest. In clients with COPD, the anteroposterior diameter of the chest often increases, giving a barrel chest appearance. This change in chest shape is due to hyperinflation of the lungs and is a common physical finding in clients with COPD and emphysema. The other options are not typically associated with COPD and emphysema. Respiratory alkalosis is not a common finding in these clients. An oxygen saturation level of 96% is within the normal range and does not specifically relate to COPD. Petechiae on the chest are not typically associated with COPD or emphysema.

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