Nursing Elites

1. A client with chronic obstructive pulmonary disease (COPD) who has been receiving oxygen therapy at 2 L/min now has a respiratory rate of 10 breaths/min. What action should the nurse take first?

• A. Increase the oxygen flow rate to 4 L/min.
• B. Administer a bronchodilator via nebulizer.
• C. Encourage the client to take deep breaths.
• D. Assess the client's mental status and level of consciousness.

Correct answer: D

Rationale: The priority action for the nurse is to assess the client's mental status and level of consciousness. This assessment helps determine if the decreased respiratory rate is affecting the client's oxygenation. By evaluating the client's mental status and level of consciousness, the nurse can promptly identify any signs of respiratory distress or hypoxia, allowing for timely intervention and appropriate adjustments to the oxygen therapy or other treatments.

2. A nurse assesses a client who has a mediastinal chest tube. Which symptoms require the nurse's immediate intervention? (Select ONE that does not apply)

• A. Production of pink sputum
• B. Tracheal deviation
• C. Pain at insertion site
• D. Sudden onset of shortness of breath

Correct answer: A

Rationale: In a client with a mediastinal chest tube, the presence of pink sputum does not necessarily require immediate intervention. However, tracheal deviation could indicate a tension pneumothorax, sudden shortness of breath could signal tube issues or pneumothorax, and drainage exceeding 70 mL/hr might suggest hemorrhage. Disconnection at the Y site could lead to air entering the tubing, necessitating prompt attention.

3. A client had a bronchoscopy 2 hours ago and asks for a drink of water. Which action should the nurse take next?

• A. Call the healthcare provider to request a prescription for food and water.
• B. Provide the client with ice chips instead of a drink of water.
• C. Assess the client's gag reflex before giving any food or water.
• D. Let the client have a small sip to assess swallowing ability.

Correct answer: C

Rationale: After a bronchoscopy, a topical anesthetic affects the gag reflex. Therefore, the nurse should assess the client's gag reflex before providing any food or water to ensure its return. This assessment is crucial to prevent aspiration or choking risk in the client.

4. A client with chronic obstructive pulmonary disease (COPD) appears thin and disheveled. Which question should the nurse ask first?

• A. Do you have a strong support system?
• B. What do you understand about your disease?
• C. Do you experience shortness of breath with basic activities?
• D. What medications are you prescribed to take each day?

Correct answer: C

Rationale: In clients with severe COPD, shortness of breath can significantly impact their ability to perform basic activities like bathing and eating. Therefore, the nurse's priority should be to assess if shortness of breath is interfering with the client's basic activities, which can provide crucial information for planning and managing care.

5. A healthcare worker is caring for a group of clients in an infectious disease unit. The worker should wear an OSHA-approved N95 respirator mask when caring for a client with which of the following infectious diseases?

• A. Pertussis
• B. Mycoplasma pneumonia
• C. Tuberculosis
• D. Respiratory syncytial virus

Correct answer: C

Rationale: An OSHA-approved N95 respirator mask is recommended when caring for a client with tuberculosis due to the airborne transmission of the disease. Tuberculosis poses a higher risk of transmission via respiratory droplets, making respiratory protection essential to prevent exposure and infection among healthcare workers.

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