Nursing Elites

1. A patient with a history of asthma is admitted with shortness of breath. What is the nurse's priority intervention?

• A. Administer a bronchodilator as prescribed.
• B. Encourage the patient to use an incentive spirometer.
• C. Place the patient in a high Fowler's position.
• D. Monitor the patient's oxygen saturation closely.

Correct answer: A

Rationale: The correct answer is to administer a bronchodilator as prescribed. This intervention is the priority for a patient with asthma experiencing shortness of breath as it helps relax the airways, making breathing easier. Encouraging the use of an incentive spirometer (Choice B) is beneficial for lung expansion but not the priority in this acute situation. Placing the patient in a high Fowler's position (Choice C) can also help with breathing but is not as immediate as administering a bronchodilator. While monitoring the patient's oxygen saturation closely (Choice D) is important, the immediate action to address the breathing difficulty is administering a bronchodilator.

2. A healthcare professional is giving a change-of-shift report about a client admitted earlier that day with pneumonia. Which of the following pieces of information is the priority for the healthcare professional to provide?

• A. Recent chest x-ray results
• B. Medication history
• C. Breath sounds
• D. Lab results

Correct answer: C

Rationale: The correct answer is C: 'Breath sounds.' When providing a change-of-shift report for a client with pneumonia, the priority information to communicate is the assessment of breath sounds. Monitoring breath sounds is crucial in assessing respiratory status and the effectiveness of treatments in pneumonia. Option A, recent chest x-ray results, may be important but does not provide real-time information on the client's current status. Option B, medication history, is relevant but not as immediate as assessing breath sounds. Option D, lab results, can provide valuable information but may not be as urgent as monitoring the client's respiratory status through breath sounds.

3. A nurse is observing a nursing student practicing standard precautions. Which observation by the instructor indicates that further teaching is necessary?

• A. The nursing student wears gloves when changing bed linens.
• B. The nursing student wears gloves to remove a wound dressing.
• C. The nursing student washes hands after removing gloves.
• D. The nursing student touches the patient's skin with sterile gloves.

Correct answer: D

Rationale: The correct answer is D because touching a patient's skin with sterile gloves compromises the sterility of the gloves, increasing the risk of contamination. Choices A, B, and C demonstrate correct practices in standard precautions. Wearing gloves when changing bed linens and to remove a wound dressing, as well as washing hands after removing gloves, are all appropriate and necessary steps to prevent the spread of infection.

4. A home health nurse is teaching about chest physiotherapy (CPT) treatments to a client with COPD. Which of the following client statements should the nurse identify as an indication that the teaching has been understood?

• A. My coughing will decrease during CPT treatments.
• B. CPT treatments will decrease my respiratory infections.
• C. I will perform postural drainage after eating meals.
• D. CPT treatments will help cure my COPD.

Correct answer: B

Rationale: The correct answer is B because chest physiotherapy (CPT) helps reduce respiratory infections by loosening mucus in the lungs. Choice A is incorrect because coughing may temporarily increase during CPT treatments as mucus is being cleared. Choice C is incorrect because postural drainage is typically performed before meals. Choice D is incorrect because while CPT can help manage symptoms and improve lung function in COPD, it does not cure the disease.

5. A nurse is caring for a client who is in labor and has an external fetal monitor in place. The nurse observes late decelerations in the fetal heart rate. Which of the following actions should the nurse take first?

• A. Decrease the client's IV fluids
• B. Reposition the client
• C. Administer oxygen by face mask
• D. Document the findings

Correct answer: C

Rationale: Administering oxygen by face mask is the priority intervention when late decelerations are observed in the fetal heart rate. Late decelerations indicate uteroplacental insufficiency, and administering oxygen helps to improve fetal oxygenation. Repositioning the client may also be necessary to relieve pressure on the umbilical cord, but providing oxygen takes precedence to enhance fetal oxygenation. Decreasing IV fluids may not directly address the underlying issue leading to late decelerations. Documenting the findings is important but should not be the first action taken when managing late decelerations.

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