Nursing Elites

1. 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.

2. A client with acute respiratory failure (ARF) is being cared for by a nurse. The nurse should monitor the client for which of the following manifestations of this condition?

• A. Severe dyspnea
• B. Nausea
• C. Decreased level of consciousness
• D. Headache

Correct answer: B

Rationale: In acute respiratory failure, the body is not getting enough oxygen, leading to hypoxia. Symptoms of hypoxia include severe dyspnea (A), decreased level of consciousness (C), and headache (D) due to inadequate oxygen supply to the brain. Nausea (B) is not a typical manifestation of acute respiratory failure and is not directly related to the lack of oxygen in the body. Therefore, the nurse should not monitor the client for nausea as a direct consequence of ARF.

3. While providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort, which of the following desired effects of medications should the nurse identify as most important for the client's recovery?

• A. It decreases the client's level of anxiety.
• B. It facilitates the client's deep breathing.
• C. It enhances the client's ability to sleep.
• D. It reduces the client's blood pressure.

Correct answer: B

Rationale: In the postoperative period following CABG surgery, deep breathing exercises are essential to prevent complications such as atelectasis and pneumonia. Opioid medications can depress the respiratory system, making it crucial for the nurse to emphasize the importance of deep breathing to maintain optimal lung function. While managing pain and anxiety are important, facilitating deep breathing takes precedence in this situation to promote effective recovery and prevent respiratory complications.

4. A client who received benzocaine spray before a recent bronchoscopy presents with continuous cyanosis despite oxygen therapy. What action should the nurse take next?

• A. Administer albuterol treatment.
• B. Notify Rapid Response Team.
• C. Assess the client's peripheral pulses.
• D. Obtain blood and sputum cultures.

Correct answer: B

Rationale: Cyanosis unresponsive to oxygen therapy suggests methemoglobinemia, an adverse effect of benzocaine spray. Methemoglobinemia can lead to death if not managed promptly. The nurse should notify the Rapid Response Team to provide immediate advanced care. Administering albuterol would not address the underlying cause of cyanosis. Assessing peripheral pulses and obtaining cultures are not the priority as they do not directly address the urgent need to manage methemoglobinemia.

5. A client with asthma presents with bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (SATA)

• A. Administer prescribed salmeterol (Serevent) inhaler.
• B. Assess the client for a tracheal deviation.
• C. Administer oxygen to maintain saturations above 94%.
• D. Perform peak expiratory flow measurements.

Correct answer: C

Rationale: Suprasternal retraction during inhalation suggests the client is using accessory muscles due to difficulty in moving air into the respiratory passages caused by airway narrowing. The presence of bilateral wheezing and decreased pulse oxygen saturation further support airway narrowing. In this situation, immediate intervention is necessary to improve oxygenation. Administering oxygen to maintain saturations above 94% is crucial to support oxygenation. While administering a rescue inhaler may be warranted, the priority in this scenario is ensuring adequate oxygenation to address the respiratory distress.

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