Nursing Elites

1. What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP) for a client receiving O2 at 4 liters per nasal cannula?

• A. Apply water-soluble ointment to nares and lips.
• B. Periodically adjust the oxygen flow rate.
• C. Remove the tubing from the client's nose.
• D. Turn the client every 2 hours or as needed.

Correct answer: A

Rationale: When a client is receiving oxygen at a high flow rate, it can cause drying of the nasal passages and lips. Therefore, a comfort measure that can be delegated to unlicensed assistive personnel (UAP) is applying water-soluble ointment to the client's nares and lips. Adjusting the oxygen flow rate should be done by licensed nursing staff, not UAP. Removing the tubing can disrupt the oxygen delivery and should be performed by trained personnel. Turning the client every 2 hours is a general comfort measure but is not specific to addressing the drying effects of oxygen therapy.

2. How does the pain of a myocardial infarction (MI) differ from stable angina?

• A. Accompanied by shortness of breath
• B. Feelings of fear or anxiety
• C. Lasts less than 15 minutes
• D. No relief from taking nitroglycerin

Correct answer: C

Rationale: The pain of a myocardial infarction (MI) is often accompanied by shortness of breath and feelings of fear or anxiety. Unlike stable angina, the pain of an MI typically lasts longer than 15 minutes and is not relieved by nitroglycerin. Additionally, it can occur without a known cause, unlike stable angina which often has a trigger such as exertion.

3. A healthcare professional auscultates a harsh hollow sound over a client's trachea & larynx. Which action should the healthcare professional take first?

• A. Document findings.
• B. Administer O2 therapy.
• C. Position client in high-Fowler's position.
• D. Administer prescribed albuterol.

Correct answer: A

Rationale: The healthcare professional has identified bronchial breath sounds, which are normal findings over the trachea & larynx, characterized by harsh, hollow, tubular, and blowing sounds. The appropriate initial action for the healthcare professional is to document these normal findings. Oxygen therapy, administering albuterol, or repositioning the client is unnecessary as this finding does not indicate a need for intervention.

4. After auscultating a client's breath sounds, the nurse is providing care. Which finding is correctly matched to the nurse's primary intervention?

• A. Hollow sounds are heard over the trachea. The nurse increases the oxygen flow rate.
• B. Crackles are heard in bases. The nurse encourages the client to cough forcefully.
• C. Wheezes are heard in central areas. The nurse administers an inhaled bronchodilator.
• D. Vesicular sounds are heard over the periphery. The nurse has the client breathe deeply.

Correct answer: C

Rationale: Wheezes are indicative of narrowed airways, and bronchodilators help to open the air passages, making option C the correct match. Wheezes are typically heard in the central or peripheral lung areas and are associated with conditions like asthma or COPD. Inhaled bronchodilators work by dilating the bronchioles, which helps alleviate wheezing and improve airflow. Therefore, administering an inhaled bronchodilator is the appropriate intervention in response to wheezes.

5. A client learns about pursed-lip breathing. Which statement by the client indicates teaching has been effective?

• A. I will breathe in quickly through my mouth and out through my nose.
• B. I will breathe in slowly through my nose and out through pursed lips.
• C. I will hold my breath for 10 seconds before exhaling.
• D. I will breathe in and out through pursed lips.

Correct answer: B

Rationale: The correct technique for pursed-lip breathing involves inhaling slowly through the nose and exhaling slowly through pursed lips. This technique helps improve expiration and reduce air trapping. Breathing in quickly, holding the breath, or breathing in and out through pursed lips does not align with the correct method of pursed-lip breathing.

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