Nursing Elites

1. When preparing a client for transfer to the ICU for placement of a pulmonary artery catheter, the nurse should explain that this catheter is used to monitor which of the following conditions?

• A. Intracranial pressure
• B. Spinal cord perfusion
• C. Renal function
• D. Hemodynamic status

Correct answer: D

Rationale: A pulmonary artery catheter is primarily used to monitor hemodynamic status. It provides essential information on cardiac output, preload, afterload, and overall cardiovascular function. This data helps healthcare providers manage the client's fluid status, cardiac function, and guide treatment interventions in critically ill patients. Monitoring intracranial pressure, spinal cord perfusion, or renal function would require different monitoring devices and techniques, not a pulmonary artery catheter.

2. A healthcare professional is preparing to administer albuterol syrup 1.6 mg PO tid. Available is albuterol 2 mg/5mL. How many mL should the healthcare professional administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

• A. 4 mL
• B. 6 mL
• C. 10 mL
• D. 5.5 mL

Correct answer: A

Rationale: To calculate the mL of albuterol syrup needed per dose, first, determine how many milligrams are in the prescribed dose: 1.6 mg. Next, set up a proportion to find the equivalent mL for 1.6 mg using the given concentration of 2 mg/5mL. The calculation is: (1.6 mg x 5 mL) / 2 mg = 4 mL. Therefore, the correct answer is 4 mL to administer per dose.

3. 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.

4. A healthcare professional auscultates a harsh hollow sound over a client's trachea & larynx. Which action should the healthcare professional take first?

• A. Document findings.
• B. Administer O2 therapy.
• C. Position client in high-Fowler's position.
• D. Administer prescribed albuterol.

Correct answer: A

Rationale: The healthcare professional has identified bronchial breath sounds, which are normal findings over the trachea & larynx, characterized by harsh, hollow, tubular, and blowing sounds. The appropriate initial action for the healthcare professional is to document these normal findings. Oxygen therapy, administering albuterol, or repositioning the client is unnecessary as this finding does not indicate a need for intervention.

5. A client is being admitted to the surgical unit from the PACU following a cholecystectomy. Which of the following assessments is the nurse's priority?

• A. Bowel sounds
• B. Surgical dressing
• C. Temperature
• D. Oxygen saturation

Correct answer: D

Rationale: The priority assessment for a client being admitted to the surgical unit following a cholecystectomy is oxygen saturation. Monitoring oxygen saturation is crucial to ensure adequate oxygenation and ventilation, especially after surgery. Hypoxia can have serious consequences and needs to be promptly addressed. While assessing bowel sounds, surgical dressing, and temperature are important, oxygen saturation takes precedence in this situation.

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