Nursing Elites

1. A client has a pulmonary embolism & is started on oxygen. The student nurse asks why the client's oxygen saturation has not significantly improved. What response by the nurse is best?

• A. Breathing so rapidly interferes with oxygenation.
• B. Maybe the client has respiratory distress syndrome.
• C. The blood clot interferes with perfusion in the lungs.
• D. The client needs immediate intubation & mechanical ventilation.

Correct answer: C

Rationale: A large blood clot in the lungs will significantly impair gas exchange & oxygenation. Unless the clot is dissolved, this process will continue unabated.

2. A client with a long history of smoking is being assessed by a nurse. Which finding is a common complication of chronic obstructive pulmonary disease (COPD)?

• A. Decreased anteroposterior chest diameter
• B. Increased breath sounds
• C. Prolonged expiratory phase
• D. Increased chest expansion

Correct answer: C

Rationale: In COPD, a prolonged expiratory phase is a typical finding caused by airway obstruction and air trapping. This results in difficulty expelling air from the lungs, leading to the characteristic prolonged exhalation in individuals with COPD.

3. 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.

4. A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this include? (SATA)

• A. Age
• B. Hypertension
• C. Obesity
• D. Smoking

Correct answer: B

Rationale: Hypertension, obesity, smoking, and excessive stress are all modifiable risk factors for coronary artery disease. Age is a nonmodifiable risk factor as it is a natural process of life.

5. When teaching a group of clients about emergency care for a snake bite, which of the following information should the nurse include?

• A. Raise the affected extremity above the level of the heart.
• B. Immobilize the affected extremity with a splint
• C. Apply ice to the bite area
• D. Apply a tourniquet to the affected extremity.

Correct answer: B

Rationale: In cases of snake bites, it is essential to immobilize the affected extremity with a splint to prevent the spread of venom throughout the body. Raising the extremity above the heart level can promote venom spread, and applying ice or a tourniquet can worsen the condition. Immobilization helps reduce movement and slows the circulation of venom, aiding in the prevention of further complications.

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