Nursing Elites

1. The nurse is assessing a 1-year-old child with bronchiolitis caused by respiratory syncytial virus (RSV). Which assessment finding requires immediate intervention?

• A. Wheezing heard on expiration
• B. Oxygen saturation of 90%
• C. Respiratory rate of 40 breaths per minute
• D. Nasal flaring with sternal retractions

Correct answer: D

Rationale: Nasal flaring with sternal retractions indicates severe respiratory distress in a 1-year-old with bronchiolitis, requiring immediate intervention. Nasal flaring and sternal retractions are signs of increased work of breathing and decreased air movement, indicating the child is struggling to breathe. Wheezing on expiration (Choice A) is common in bronchiolitis but may not require immediate intervention. An oxygen saturation of 90% (Choice B) is low but may not be the most critical finding in this case. A respiratory rate of 40 breaths per minute (Choice C) is elevated but alone may not indicate the need for immediate intervention as much as nasal flaring and sternal retractions.

2. A 46-year-old male client who had a myocardial infarction 24 hours ago comes to the nurse's station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which nursing problem should the nurse formulate?

• A. Ineffective coping related to denial.
• B. Risk for impaired cardiac function.
• C. Noncompliance related to lack of knowledge.
• D. Anxiety related to hospitalization.

Correct answer: A

Rationale: The correct answer is A: Ineffective coping related to denial. The client's desire to leave the hospital shortly after a myocardial infarction despite the severity of the condition indicates denial and ineffective coping. This behavior could lead to complications as the client may not adequately address his health needs. Choice B, Risk for impaired cardiac function, is not the most appropriate nursing problem in this scenario as the client's behavior is more indicative of psychological coping issues rather than a direct physiological risk at this moment. Choice C, Noncompliance related to lack of knowledge, does not align with the client's behavior of wanting to leave the hospital. Choice D, Anxiety related to hospitalization, may not be the best option as the client's behavior is more suggestive of denial rather than anxiety about being hospitalized.

3. An adolescent's mother calls the clinic because the teen is having recurrent vomiting and has become combative in the last 2 days. The mother states that the teen takes vitamins, calcium, magnesium, and aspirin. Which nursing intervention has the highest priority?

• A. Advise the mother to withhold all medications by mouth.
• B. Instruct the mother to take the teen to the emergency room.
• C. Recommend that the teen withhold food and fluids for 2 hours.
• D. Suggest that the adolescent breathe slowly and deeply.

Correct answer: B

Rationale: The correct answer is to instruct the mother to take the teen to the emergency room. The symptoms described, including recurrent vomiting and becoming combative after taking vitamins, calcium, magnesium, and aspirin, indicate a potential overdose or a serious condition. Therefore, immediate medical evaluation in the emergency room is crucial. Advising to withhold all medications by mouth (Choice A) may delay necessary treatment. Recommending to withhold food and fluids (Choice C) is not appropriate in this urgent situation. Suggesting deep breathing (Choice D) does not address the seriousness of the symptoms and the need for immediate medical attention.

4. A client with end-stage renal disease (ESRD) is scheduled for hemodialysis. Which clinical finding requires immediate intervention?

• A. Fever of 100.4°F
• B. Heart rate of 110 beats per minute
• C. Blood pressure of 140/90 mmHg
• D. Respiratory rate of 24 breaths per minute

Correct answer: A

Rationale: A fever of 100.4°F is a clinical finding that requires immediate intervention in a client with ESRD scheduled for hemodialysis. Fever may indicate an underlying infection, which can be severe in individuals with compromised renal function. Prompt assessment and treatment are essential to prevent worsening of the infection and potential complications. Heart rate, blood pressure, and respiratory rate are also important parameters to monitor in clients with ESRD, but in this scenario, the fever takes precedence due to its potential to indicate a critical condition that requires urgent attention.

5. An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement?

• A. Auscultate for renal bruits
• B. Obtain a clean catch mid-stream specimen
• C. Use a dipstick to measure for urinary ketones
• D. Begin to strain the client's urine

Correct answer: B

Rationale: This elderly client is presenting symptoms consistent with a urinary tract infection (UTI), such as confusion, nausea, dysuria, urgency, and incontinence. The best course of action for the nurse is to obtain a clean catch mid-stream specimen. This specimen will help identify the causative agent of the UTI, allowing for targeted treatment with an appropriate anti-infective agent. Auscultating for renal bruits (Choice A) is not indicated in this scenario as the client's symptoms point towards a UTI rather than a renal issue. Using a dipstick to measure for urinary ketones (Choice C) is not relevant in the context of UTI symptoms. Beginning to strain the client's urine (Choice D) would not address the need to identify the causative agent for targeted treatment.

Similar Questions