Nursing Elites

1. A 17-year-old adolescent reports flu-like symptoms and is brought to the emergency room. What intervention should the nurse implement first?

• A. Assess the client's temperature.
• B. Place a mask on the client.
• C. Obtain a chest X-ray per protocol.
• D. Determine the client's blood pressure.

Correct answer: B

Rationale: The correct answer is to place a mask on the client. This intervention is crucial in preventing the spread of infections like the flu, especially in a healthcare setting where the risk of transmission is high. Assessing the client's temperature (Choice A) can be important but is not the priority in this situation. Obtaining a chest X-ray (Choice C) and determining the client's blood pressure (Choice D) are not the immediate interventions needed for a 17-year-old reporting flu-like symptoms.

2. A client asks the nurse to call the police and states: 'I need to report that I am being abused by a nurse.' The nurse should first

• A. Focus on reality orientation to place and person
• B. Assist with the report of the client's complaint to the police
• C. Obtain more details of the client's claim of abuse
• D. Document the statement in the client's chart with a report to the manager

Correct answer: C

Rationale: The correct initial action for the nurse is to obtain more details about the client's claim of abuse. This will help the nurse better understand the situation before proceeding with any further actions. Option A is incorrect as reality orientation is not the priority in this situation. Option B is premature as more details are needed first. Option D is not the immediate step as gathering information should come before documentation and reporting.

3. A client with chronic obstructive pulmonary disease (COPD) presents with a respiratory rate of 32 breaths per minute and an oxygen saturation of 86%. What is the nurse's first action?

• A. Administer oxygen at 2 L/min via nasal cannula.
• B. Notify the healthcare provider immediately.
• C. Position the client in high Fowler's position.
• D. Suction the client's airway.

Correct answer: A

Rationale: Administering oxygen at 2 L/min via nasal cannula is the nurse's first action when a client with COPD presents with a respiratory rate of 32 breaths per minute and an oxygen saturation of 86%. Oxygen therapy helps improve oxygen saturation in patients with COPD and respiratory distress. While notifying the healthcare provider is important, immediate intervention to improve oxygenation takes priority. Positioning the client in high Fowler's position can also assist with breathing but is not the initial action in this scenario. Suctioning the airway is not indicated unless there are secretions obstructing the airway, which is not mentioned in the scenario.

4. A client with pneumonia is receiving oxygen therapy. What assessment finding requires immediate intervention?

• A. Increased oxygen saturation of 96%.
• B. Oxygen saturation of 89%.
• C. Respiratory rate of 20 breaths per minute.
• D. Decreased heart rate of 70 beats per minute.

Correct answer: B

Rationale: The correct answer is B. An oxygen saturation of 89% indicates hypoxemia, which is below the normal range (usually 95-100%). This finding requires immediate intervention as it signifies inadequate oxygenation. Options A, C, and D are within normal limits and do not indicate an urgent need for intervention. Option A indicates a good oxygen saturation level, option C denotes a normal respiratory rate, and option D suggests a normal heart rate. Therefore, these options do not require immediate intervention compared to the critically low oxygen saturation level of 89% in option B.

5. A client with chronic kidney disease is prescribed a low-potassium diet. Which food should the nurse instruct the client to avoid?

• A. Carrots
• B. White bread
• C. Bananas
• D. Apples

Correct answer: C

Rationale: The correct answer is C: Bananas. Bananas are high in potassium and should be avoided in clients who are on a low-potassium diet due to chronic kidney disease. Foods like apples and white bread are low in potassium and are safer choices. Carrots are also low in potassium and do not need to be avoided in this case.

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