Nursing Elites

1. A client who received benzocaine spray before a recent bronchoscopy presents with continuous cyanosis despite oxygen therapy. What action should the nurse take next?

• A. Administer albuterol treatment.
• B. Notify Rapid Response Team.
• C. Assess the client's peripheral pulses.
• D. Obtain blood and sputum cultures.

Correct answer: B

Rationale: Cyanosis unresponsive to oxygen therapy suggests methemoglobinemia, an adverse effect of benzocaine spray. Methemoglobinemia can lead to death if not managed promptly. The nurse should notify the Rapid Response Team to provide immediate advanced care. Administering albuterol would not address the underlying cause of cyanosis. Assessing peripheral pulses and obtaining cultures are not the priority as they do not directly address the urgent need to manage methemoglobinemia.

2. While caring for a client with extensive partial and full-thickness burns of the head, neck, and chest, which risk should the nurse prioritize for assessment and intervention?

• A. Airway obstruction
• B. Infection
• C. Fluid imbalance
• D. Paralytic ileus

Correct answer: A

Rationale: When a client sustains burns to the head, neck, or chest, the risk of airway obstruction is a critical concern due to potential swelling, inflammation, or inhalation injury. Any compromise to the airway can lead to severe respiratory distress or failure. Early recognition and intervention to maintain a clear airway are essential to prevent life-threatening complications in burn patients.

3. A college health nurse interprets the peak expiratory flow rate for a student who has asthma and finds that the student is in the yellow zone of his asthma action plan. The nurse should not base her actions on which of the following information?

• A. The student should use his quick-relief inhaler.
• B. The student's asthma is not well controlled.
• C. The student's peak flow is 50% to 80% of his best peak flow.
• D. The student needs to go to the hospital

Correct answer: D

Rationale: In an asthma action plan, the yellow zone indicates caution and signals a need to monitor symptoms closely. When a student is in the yellow zone, the appropriate action is to follow the prescribed steps, which typically include using a quick-relief inhaler and closely monitoring peak flow. Going to the hospital is usually reserved for severe asthma exacerbations in the red zone. Therefore, the information that the student needs to go to the hospital is not typically appropriate when the student is in the yellow zone.

4. 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.

5. When caring for a client with Alzheimer's disease, what is the most appropriate communication technique for a nurse to use?

• A. Providing detailed explanations
• B. Speaking in a loud and clear voice
• C. Using simple and direct statements
• D. Offering multiple choices to the client

Correct answer: C

Rationale: When communicating with clients with Alzheimer's disease, using simple and direct statements is the most appropriate technique. This approach helps to minimize confusion, enhance understanding, and facilitate effective communication with individuals who may have difficulty processing complex information due to their condition.

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