Nursing Elites

1. A nurse is performing a focused assessment on a client with a history of chronic obstructive pulmonary disease (COPD). What finding should the nurse expect?

• A. Increased breath sounds
• B. Flushed skin
• C. Nasal flaring
• D. Decreased respiratory rate

Correct answer: B

Rationale: The correct answer is B: Flushed skin. Flushed skin is a common finding in clients with COPD who are experiencing dyspnea. Increased breath sounds (choice A) are not typically associated with COPD; they may indicate conditions like pneumonia. Nasal flaring (choice C) is more commonly seen in respiratory distress in pediatric patients. Decreased respiratory rate (choice D) is not a typical finding in COPD and could indicate respiratory depression.

2. A nurse is caring for a client who has an indwelling urinary catheter. What should the nurse identify as a sign of catheter occlusion?

• A. Bladder spasms
• B. Bladder distention
• C. Frequent urination
• D. Hematuria

Correct answer: B

Rationale: The correct answer is B: Bladder distention. Bladder distention is a sign of catheter occlusion because it indicates a failure to drain urine properly. Bladder spasms (Choice A) are more commonly associated with bladder irritability rather than catheter occlusion. Frequent urination (Choice C) is unlikely in a client with an indwelling catheter as the urine should be draining continuously. Hematuria (Choice D) refers to blood in the urine and is not typically a direct sign of catheter occlusion.

3. A nurse is reviewing the lab report of a client who has been experiencing a fever for the last 3 days. What lab result indicates the client is experiencing fluid volume deficit (FVD)?

• A. Decreased BUN levels
• B. Increased hematocrit
• C. Increased white blood cell count
• D. Decreased hematocrit

Correct answer: B

Rationale: The correct answer is B: Increased hematocrit. Increased hematocrit indicates hemoconcentration, which is a sign of fluid volume deficit. When there is a decrease in fluid volume in the body, the blood becomes more concentrated, leading to an increase in hematocrit levels. Choices A, C, and D are incorrect because decreased BUN levels, increased white blood cell count, and decreased hematocrit are not indicative of fluid volume deficit.

4. A nurse is assessing the IV infusion site of a client who reports pain at the site. The site is red, and there is warmth along the course of the vein. What should the nurse do?

• A. Increase the IV flow rate
• B. Discontinue the infusion
• C. Elevate the limb
• D. Apply a cold compress

Correct answer: B

Rationale: The correct answer is to discontinue the infusion (Choice B) as the signs described suggest phlebitis, an inflammation of the vein. Increasing the IV flow rate (Choice A) can exacerbate the condition by increasing the irritation. Elevating the limb (Choice C) and applying a cold compress (Choice D) are not the appropriate interventions for phlebitis. Elevation and cold therapy are more suitable for conditions like swelling or inflammation, but in this case, discontinuing the infusion is the priority to prevent further complications.

5. A nurse is preparing to perform an abdominal assessment on a client. Which action should the nurse take first?

• A. Percuss the abdomen
• B. Inspect the abdomen
• C. Auscultate before palpation
• D. Palpate the abdomen

Correct answer: C

Rationale: The correct answer is to auscultate before palpation. This ensures that bowel sounds are not altered by physical manipulation. Inspecting the abdomen is a valid step but not the first. Percussing and palpating should come after auscultation to prevent altering bowel sounds or causing discomfort to the client.

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