Nursing Elites

1. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which clinical finding requires immediate intervention?

• A. Oxygen saturation of 90%
• B. Respiratory rate of 24 breaths per minute
• C. Use of accessory muscles
• D. Inspiratory crackles

Correct answer: C

Rationale: The correct answer is C: Use of accessory muscles. In a client with COPD receiving supplemental oxygen, the use of accessory muscles is a critical finding that requires immediate intervention. This observation indicates increased work of breathing, suggesting respiratory distress. Addressing this issue promptly is crucial to prevent further respiratory compromise. Choice A, oxygen saturation of 90%, is slightly below the normal range but may not require immediate intervention unless it continues to decrease. Choice B, a respiratory rate of 24 breaths per minute, is within normal limits for an adult and does not indicate an urgent issue. Choice D, inspiratory crackles, may be present in COPD due to secretions or inflammation but do not necessitate immediate intervention unless associated with other concerning signs.

2. Following an open reduction of the tibia, the nurse notes bleeding on the client's cast. Which action should the nurse implement?

• A. Outline the area with ink and check it every 15 minutes to see if the area has increased
• B. Notify the healthcare provider immediately
• C. Apply a new cast to stop the bleeding
• D. Elevate the limb to reduce blood flow

Correct answer: A

Rationale: After an open reduction of the tibia, bleeding on the cast can be a concern. Outlining the area with ink and monitoring it every 15 minutes is the appropriate action to assess if the bleeding is worsening, indicating the need for further intervention. This action allows for close observation without disturbing the cast. Choice B is incorrect because while notifying the healthcare provider is important, immediate action is not always necessary if the bleeding is not severe. Choice C is incorrect because applying a new cast is not the standard intervention for bleeding on a cast. Choice D is incorrect because elevating the limb may not address the underlying cause of bleeding and may not be the most appropriate action at this time.

3. A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which intervention should the nurse implement first?

• A. Administer intravenous insulin as prescribed.
• B. Monitor the client's urine output.
• C. Administer intravenous fluids.
• D. Administer 50% dextrose IV push.

Correct answer: A

Rationale: Administering intravenous insulin is the initial priority in managing diabetic ketoacidosis (DKA). Insulin helps to reduce blood glucose levels and correct metabolic acidosis, addressing the underlying cause of DKA. Monitoring urine output (choice B) is important but is not the first intervention needed. Administering intravenous fluids (choice C) is essential to correct dehydration in DKA, but insulin therapy takes precedence. Administering 50% dextrose IV push (choice D) is contraindicated in DKA as it can exacerbate hyperglycemia.

4. In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client's respiratory rate is 14 breaths/minute. What action should the nurse implement?

• A. Encourage the client to take deep breaths
• B. Remove the mask to deflate the bag
• C. Increase the liter flow of oxygen
• D. Document the assessment data

Correct answer: D

Rationale: The correct action for the nurse to implement is to document the assessment data. In this scenario, the findings indicate that the partial rebreather mask is functioning correctly as the reservoir bag should not deflate completely during inspiration. Additionally, the client's respiratory rate of 14 breaths/minute falls within the normal range. There is no need to encourage the client to take deep breaths, as the respiratory rate is normal, and doing so may disrupt the client's breathing pattern. Removing the mask to deflate the bag or increasing the liter flow of oxygen are unnecessary actions based on the assessment findings.

5. The nurse is caring for a client with a history of atrial fibrillation who is receiving warfarin (Coumadin). Which laboratory value should be closely monitored?

• A. Serum potassium level
• B. Prothrombin time (PT)
• C. International Normalized Ratio (INR)
• D. Serum sodium level

Correct answer: C

Rationale: The correct answer is C, International Normalized Ratio (INR). The INR should be closely monitored in a client receiving warfarin (Coumadin) to assess the effectiveness and safety of anticoagulation therapy. Monitoring the INR helps ensure that the client is within the therapeutic range for anticoagulation to prevent complications such as bleeding or clotting. Choices A, B, and D are incorrect. While monitoring electrolyte levels like serum potassium and sodium is important in overall client care, they are not specific to monitoring the effects of warfarin therapy. Prothrombin time (PT) is a component of INR and helps in monitoring warfarin therapy, but INR gives a standardized result that is independent of the laboratory method used, making it the preferred choice for monitoring warfarin therapy.

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