Nursing Elites

1. During the care of a client with Legionnaire's disease, which finding would require the nurse's immediate attention?

• A. Pleuritic pain on inspiration
• B. Dry mucus membranes in the mouth
• C. A decrease in respiratory rate from 34 to 24
• D. Decrease in chest wall expansion

Correct answer: D

Rationale: A decrease in chest wall expansion suggests that the client may be experiencing a serious complication, such as worsening pneumonia or respiratory failure, requiring immediate medical attention. This finding indicates a potential decrease in lung function, which could lead to respiratory distress. Pleuritic pain on inspiration may be related to the disease process but does not indicate an immediate need for intervention. Dry mucus membranes in the mouth may require attention but are not as critical as a decrease in chest wall expansion. A decrease in respiratory rate could be concerning but is not as urgent as a decrease in chest wall expansion, which directly impacts respiratory function.

2. To prevent keratitis in an unconscious client, where should the nurse apply moisturizing ointment?

• A. Finger and toenail quicks
• B. Eyes
• C. Perianal area
• D. External ear canals

Correct answer: B

Rationale: The correct answer is B: Eyes. Applying moisturizing ointment to the eyes helps prevent keratitis, a condition that can occur due to inadequate blinking in unconscious clients, leading to corneal dryness and potential damage. Choices A, C, and D are incorrect as moisturizing ointment should not be applied to finger and toenail quicks, perianal area, or external ear canals to prevent keratitis.

3. The healthcare professional enters the room as a 3-year-old is having a generalized seizure. Which intervention should the healthcare professional do first?

• A. Clear the area of any hazards
• B. Place the child on the side
• C. Restrain the child
• D. Give the prescribed anticonvulsant

Correct answer: B

Rationale: Placing the child on the side is the priority intervention during a generalized seizure as it helps maintain an open airway and prevents aspiration. Clearing the area of any hazards is important but should come after ensuring the child's safety. Restraining the child is not recommended during a seizure as it can lead to injury. Giving the prescribed anticonvulsant is important but should not be the first action during an ongoing seizure.

4. What does the acronym ICD stand for in medical terminology?

• A. International Classification of Diseases
• B. Internal Care Documentation
• C. Intensive Care Division
• D. Integrated Care Department

Correct answer: A

Rationale: The correct answer is A: International Classification of Diseases. The ICD is a system used worldwide to classify and code various health conditions and diseases. This system helps in standardizing the documentation and coding of diseases, which is essential for epidemiology, research, and healthcare management. Choices B, C, and D are incorrect as they do not represent the widely recognized meaning of the acronym ICD in medical terminology.

5. A client with asthma has low-pitched wheezes present on the final half of exhalation. One hour later the client has high-pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client

• A. Has increased airway obstruction
• B. Has improved airway obstruction
• C. Needs to be suctioned
• D. Exhibits hyperventilation

Correct answer: A

Rationale: The correct answer is A: 'Has increased airway obstruction.' High-pitched wheezes extending throughout exhalation indicate a worsening airway obstruction, leading to increased resistance in the airways. Low-pitched wheezes present on the final half of exhalation may suggest some level of obstruction, but the change to high-pitched wheezes throughout exhalation indicates a progression in the obstruction. Choice B is incorrect as the change in wheeze characteristics signifies deterioration rather than improvement. Choice C is incorrect as suctioning is not indicated based on the wheeze assessment findings. Choice D is incorrect as hyperventilation does not typically present with wheezes and is not supported by the information provided.

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