Nursing Elites

1. A client with acute respiratory failure (ARF) is being cared for by a nurse. The nurse should monitor the client for which of the following manifestations of this condition?

• A. Severe dyspnea
• B. Nausea
• C. Decreased level of consciousness
• D. Headache

Correct answer: B

Rationale: In acute respiratory failure, the body is not getting enough oxygen, leading to hypoxia. Symptoms of hypoxia include severe dyspnea (A), decreased level of consciousness (C), and headache (D) due to inadequate oxygen supply to the brain. Nausea (B) is not a typical manifestation of acute respiratory failure and is not directly related to the lack of oxygen in the body. Therefore, the nurse should not monitor the client for nausea as a direct consequence of ARF.

2. A client is vomiting. Which of the following actions should the nurse take first?

• A. Provide the client with an emesis basin
• B. Notify housekeeping
• C. Prevent the client from aspirating
• D. Administer an antiemetic to the client

Correct answer: C

Rationale: When a client is vomiting, the priority action for the nurse is to prevent the client from aspirating. Aspiration can lead to serious respiratory complications. Providing the client with an emesis basin can be helpful but preventing aspiration takes precedence. Notifying housekeeping and administering an antiemetic are secondary actions that can be addressed once the client's safety is ensured.

3. A client has burns to his face, ears, and eyelids. What is the priority finding for the nurse to report to the provider?

• A. Urinary output of 25 mL/hr
• B. Difficulty swallowing
• C. Heart rate of 122/min
• D. Pain level of 6 on a scale of 0 to 10

Correct answer: B

Rationale: When a client has burns involving the face, ears, and eyelids, the priority finding to report to the provider is difficulty swallowing. This symptom could indicate potential airway compromise or swelling in the throat, which can lead to serious complications. Monitoring and addressing this issue promptly is crucial to ensure the client's airway remains patent and secure.

4. 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.

5. 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.

Similar Questions