Nursing Elites

1. A nurse is assessing a client with a history of seizures. Which assessment finding requires immediate intervention?

• A. The client is experiencing an aura.
• B. The client's antiseizure medication level is within the therapeutic range.
• C. The client has been seizure-free for 2 years.
• D. The client's seizure activity lasts longer than 5 minutes.

Correct answer: D

Rationale: Seizure activity lasting longer than 5 minutes requires immediate intervention as it can lead to status epilepticus, a medical emergency.

2. A client with a long history of smoking is being assessed by a nurse. Which finding is a common complication of chronic obstructive pulmonary disease (COPD)?

• A. Decreased anteroposterior chest diameter
• B. Increased breath sounds
• C. Prolonged expiratory phase
• D. Increased chest expansion

Correct answer: C

Rationale: In COPD, a prolonged expiratory phase is a typical finding caused by airway obstruction and air trapping. This results in difficulty expelling air from the lungs, leading to the characteristic prolonged exhalation in individuals with COPD.

3. A client with a tracheostomy experienced a coughing spell during a meal that was being fed by an unlicensed assistive personnel (UAP). What action by the nurse takes priority?

• A. Assess the client's lung sounds.
• B. Assign a different UAP to the client.
• C. Report the UAP to the manager.
• D. Request thicker liquids for meals.

Correct answer: A

Rationale: The priority action for the nurse is to assess the client's lung sounds to check for signs of aspiration, which can compromise the client's oxygenation. This is crucial to ensure the client's immediate safety and respiratory status. Once the client has been assessed, the nurse can then consider consulting with the registered dietitian regarding appropriate thickened liquids for future meals. Assigning a different UAP or reporting the UAP to the manager may be necessary steps but not the immediate priority in this situation.

4. A client with a pleural effusion is being assessed by a nurse. Which clinical manifestation does the nurse expect to find?

• A. Decreased breath sounds on the affected side
• B. Hyperresonance on percussion of the affected side
• C. Increased tactile fremitus on the affected side
• D. Tracheal deviation toward the affected side

Correct answer: A

Rationale: In a client with pleural effusion, decreased breath sounds on the affected side are common due to the presence of fluid in the pleural space. Hyperresonance is not expected; dullness on percussion is more likely. Tactile fremitus is typically decreased, not increased, in pleural effusion cases. Tracheal deviation away from the affected side, not toward it, can be seen with large effusions.

5. While providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort, which of the following desired effects of medications should the nurse identify as most important for the client's recovery?

• A. It decreases the client's level of anxiety.
• B. It facilitates the client's deep breathing.
• C. It enhances the client's ability to sleep.
• D. It reduces the client's blood pressure.

Correct answer: B

Rationale: In the postoperative period following CABG surgery, deep breathing exercises are essential to prevent complications such as atelectasis and pneumonia. Opioid medications can depress the respiratory system, making it crucial for the nurse to emphasize the importance of deep breathing to maintain optimal lung function. While managing pain and anxiety are important, facilitating deep breathing takes precedence in this situation to promote effective recovery and prevent respiratory complications.

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