Nursing Elites

1. The healthcare provider is assessing a client with chronic obstructive pulmonary disease (COPD). Which finding requires immediate intervention?

• A. Oxygen saturation of 88%.
• B. Use of accessory muscles for breathing.
• C. Respiratory rate of 26 breaths per minute.
• D. Barrel-shaped chest.

Correct answer: C

Rationale: A respiratory rate of 26 breaths per minute is an abnormal finding and indicates that the client is experiencing respiratory distress, requiring immediate intervention. This rapid respiratory rate can signify inadequate oxygenation and ventilation. Oxygen saturation of 88% is low but not as immediately concerning as a high respiratory rate, which indicates the body is compensating for respiratory distress. The use of accessory muscles for breathing and a barrel-shaped chest are typical findings in clients with COPD but do not indicate an immediate need for intervention as they are more chronic in nature and may be seen in stable COPD patients.

2. The healthcare provider is conducting a health assessment for a family living in a high-crime area. Which intervention should the healthcare provider prioritize to ensure the family's safety?

• A. providing information on local crime statistics
• B. teaching the family self-defense techniques
• C. helping the family develop a safety plan
• D. encouraging the family to move to a safer neighborhood

Correct answer: C

Rationale: Developing a safety plan is the most appropriate intervention as it helps the family prepare for potential emergencies and enhances their overall sense of security. Providing information on local crime statistics may raise awareness but does not directly address safety planning. Teaching self-defense techniques may have limited effectiveness in a high-crime area where the family may face multiple threats. Encouraging the family to move to a safer neighborhood is not always feasible due to various reasons such as financial constraints or social ties to the current community.

3. The nurse obtains a heart rate of 92 and a blood pressure of 110/76 before administering a scheduled dose of verapamil (Calan) for a client with atrial flutter. Which action should the nurse implement?

• A. Administer the dose as prescribed.
• B. Hold the medication.
• C. Call the healthcare provider.
• D. Repeat the vital signs in 30 minutes.

Correct answer: A

Rationale: The correct action is to administer the dose as prescribed. Verapamil slows sinoatrial nodal automaticity and delays atrioventricular nodal conduction, which helps in slowing the ventricular rate. The heart rate of 92 and blood pressure of 110/76 are within an acceptable range for administering verapamil in a client with atrial flutter. Holding the medication, calling the healthcare provider, or repeating the vital signs in 30 minutes are not necessary based on the vital signs obtained and the action of verapamil in this scenario.

4. The healthcare professional is developing a program to educate parents on childhood safety. Which topic should be prioritized?

• A. the benefits of car seats
• B. how to childproof the home
• C. the importance of helmet use
• D. ways to prevent drowning

Correct answer: B

Rationale: Prioritizing the topic of how to childproof the home is crucial as it provides a holistic approach to safeguarding children from various injuries within the home environment. Childproofing the home addresses a wide range of hazards such as falls, burns, poisoning, and choking incidents. While topics like the benefits of car seats, the importance of helmet use, and ways to prevent drowning are important, childproofing the home covers a broader spectrum of safety measures that can significantly reduce the risk of injuries for children.

5. A client with chronic kidney disease is receiving erythropoietin therapy. Which finding indicates that the therapy is effective?

• A. Hemoglobin of 12 g/dL.
• B. Reticulocyte count of 1%.
• C. Blood pressure of 130/80 mm Hg.
• D. Serum ferritin level of 100 ng/mL.

Correct answer: A

Rationale: The correct answer is A: Hemoglobin of 12 g/dL. Erythropoietin therapy stimulates red blood cell production, leading to an increase in hemoglobin levels. A hemoglobin level of 12 g/dL indicates that the therapy is effective in managing anemia associated with chronic kidney disease. Choice B, a reticulocyte count of 1%, is not a direct indicator of the effectiveness of erythropoietin therapy. Choice C, a blood pressure of 130/80 mm Hg, is important to monitor in clients with chronic kidney disease but does not specifically indicate the effectiveness of erythropoietin therapy. Choice D, a serum ferritin level of 100 ng/mL, is related to iron stores in the body and may be monitored during erythropoietin therapy but does not directly reflect the therapy's effectiveness in increasing red blood cell production.

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