Nursing Elites

1. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which intervention should the nurse implement first?

• A. Administer a bronchodilator as prescribed.
• B. Assess the client's respiratory rate.
• C. Assess the client's oxygen saturation.
• D. Elevate the head of the bed.

Correct answer: C

Rationale: Assessing the client's oxygen saturation is crucial in a client with COPD receiving supplemental oxygen to ensure adequate oxygenation. This assessment helps determine if the current oxygen therapy is effective or if adjustments are necessary. While administering a bronchodilator is important in managing COPD, assessing oxygen saturation takes precedence to address the client's immediate oxygen needs. Assessing the respiratory rate is also important but evaluating oxygen saturation provides more direct information about the client's oxygen status. Elevating the head of the bed can improve ventilation but is not the priority when assessing oxygen saturation in a client with COPD receiving supplemental oxygen.

2. In determining the client position for insertion of an indwelling urinary catheter, it is most important for the nurse to recognize which client condition?

• A. High urinary pH
• B. Abdominal ascites
• C. Orthopnea
• D. Fever

Correct answer: C

Rationale: The correct answer is C: Orthopnea. If the client is orthopneic, the nurse needs to adapt the insertion position that does not place the client in a supine position. This means the head of the bed should be elevated as much as possible to facilitate catheter insertion without compromising the client's breathing. High urinary pH (choice A) is not directly relevant to the insertion position of a urinary catheter. Abdominal ascites (choice B) may impact the procedure due to abdominal distension but is not as crucial as orthopnea. Fever (choice D) does not specifically affect the client's position for urinary catheter insertion.

3. A male client notifies the nurse that he feels short of breath and has chest pressure radiating down his left arm. A STAT 12-lead electrocardiogram (ECG) is obtained and shows ST segment elevation in leads II, III, aVF, and V4R. The nurse collects blood samples and gives a normal saline bolus. What action is most important for the nurse to implement?

• A. Obtain the results for STAT serum cardiac biomarkers.
• B. Assess for contraindications for thrombolytic therapy.
• C. Measure ST-segment height and waveform changes.
• D. Transfer for percutaneous coronary intervention (PCI).

Correct answer: B

Rationale: Assessing for contraindications for thrombolytic therapy is crucial as it determines whether the client is a candidate for reperfusion therapy. In this scenario, the client is presenting with symptoms and ECG changes consistent with an acute myocardial infarction (MI). Thrombolytic therapy aims at restoring blood flow to the heart muscle, reducing the size of the infarct. However, it is essential to assess for contraindications such as recent surgery, active bleeding, or a history of stroke to avoid potential complications. Obtaining serum cardiac biomarkers or measuring ST-segment changes are important steps in the diagnosis of MI but are not as time-sensitive as assessing for contraindications to thrombolytic therapy. Transfer for percutaneous coronary intervention (PCI) is a definitive treatment for MI, but assessing for thrombolytic therapy eligibility takes precedence in this acute situation.

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. To reduce the risk of being named in a malpractice lawsuit, which action is most important for the nurse to take?

• A. Adhere consistently to standards of care.
• B. Thoroughly document all client interactions.
• C. Build a good rapport with clients.
• D. Work closely with the healthcare team.

Correct answer: A

Rationale: Adhering consistently to standards of care is crucial for nurses to reduce the risk of being named in a malpractice lawsuit. Following established protocols and guidelines ensures that the care provided is safe and effective. Thoroughly documenting all client interactions is also essential to support the care provided and to have a record of the interventions. Building a good rapport with clients is important for communication and trust but does not directly reduce the risk of malpractice. Working closely with the healthcare team is valuable for collaboration but might not directly impact the risk of malpractice unless it relates to following standards of care.

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