Nursing Elites

1. During an assessment, a client with a long history of smoking and suspected laryngeal cancer will most likely report which early manifestation?

• A. Dysphagia
• B. Hoarseness
• C. Dyspnea
• D. Weight loss

Correct answer: B

Rationale: In clients with laryngeal cancer, hoarseness is often one of the earliest manifestations due to vocal cord involvement. The irritation and inflammation caused by the tumor affect the vocal cords, leading to changes in voice quality. Dysphagia (choice A) typically occurs later as the tumor grows and interferes with swallowing. Dyspnea (choice C) and weight loss (choice D) may occur as the cancer progresses, but hoarseness is usually among the first signs to manifest in laryngeal cancer.

2. A client with chronic obstructive pulmonary disease (COPD) who has been receiving oxygen therapy at 2 L/min now has a respiratory rate of 10 breaths/min. What action should the nurse take first?

• A. Increase the oxygen flow rate to 4 L/min.
• B. Administer a bronchodilator via nebulizer.
• C. Encourage the client to take deep breaths.
• D. Assess the client's mental status and level of consciousness.

Correct answer: D

Rationale: The priority action for the nurse is to assess the client's mental status and level of consciousness. This assessment helps determine if the decreased respiratory rate is affecting the client's oxygenation. By evaluating the client's mental status and level of consciousness, the nurse can promptly identify any signs of respiratory distress or hypoxia, allowing for timely intervention and appropriate adjustments to the oxygen therapy or other treatments.

3. While caring for a client using O2 in the hospital, what assessment finding indicates that goals for a priority diagnosis are being met?

• A. 100% of meals being eaten by the client
• B. Intact skin behind the ears
• C. The client understanding the need for oxygen
• D. Unchanged weight for the past 3 days

Correct answer: B

Rationale: When a client is using oxygen, there is a risk for impaired skin integrity due to pressure from tubing. Intact skin behind the ears suggests that the client is not experiencing skin breakdown, meeting the goals for this diagnosis. The client's nutrition, understanding of oxygen therapy, and weight stability are important but do not directly relate to the priority diagnosis of skin integrity in this context.

4. A client with chronic obstructive pulmonary disease (COPD tells the nurse, 'I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up.' Which of the following actions should the nurse take to help this client with tenacious bronchial secretions?

• A. Maintaining a semi-Fowler's position as often as possible
• B. Administering oxygen via nasal cannula at 2 L/min
• C. Helping the client select a low-salt diet
• D. Encouraging the client to drink 2 to 3 L of water daily

Correct answer: D

Rationale: Encouraging the client to drink 2 to 3 liters of water daily helps to thin bronchial secretions, making them easier to expectorate. This can assist the client in coughing up the tenacious secretions. Maintaining a semi-Fowler's position can aid in improving lung expansion but may not directly address the issue of clearing the secretions. Administering oxygen via nasal cannula at 2 L/min can help improve oxygenation but does not specifically target the removal of bronchial secretions. Selecting a low-salt diet is important for overall health, but it does not directly address the client's immediate concern of clearing the bronchial secretions.

5. Which action best demonstrates respect for autonomy when working with a client?

• A. Asks if the client has questions before signing a consent form
• B. Provides the client with accurate information when questioned
• C. Honors the promises made to the client and family
• D. Ensures fair treatment of the client compared to others

Correct answer: A

Rationale: Respect for autonomy involves allowing individuals to make decisions about their care. By asking if the client has questions before signing a consent form, the nurse is respecting the client's right to make informed choices and decisions regarding their healthcare. This action supports the principle of self-determination and autonomy in healthcare decision-making.

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