Nursing Elites

1. A client with a history of asthma is admitted with shortness of breath. Which finding requires immediate intervention?

• A. Increased respiratory rate.
• B. Absence of breath sounds.
• C. Expiratory wheezes.
• D. Productive cough with green sputum.

Correct answer: B

Rationale: The correct answer is B: Absence of breath sounds. This finding can indicate a pneumothorax or severe asthma exacerbation, both of which require immediate intervention to ensure adequate ventilation and prevent further complications. Increased respiratory rate (choice A) is common in asthma exacerbations but may not always necessitate immediate intervention. Expiratory wheezes (choice C) are typical in asthma and may not always indicate a critical condition. A productive cough with green sputum (choice D) suggests a possible respiratory infection but does not warrant immediate intervention as much as the absence of breath sounds.

2. The client, who is 6 weeks pregnant, is being educated by the nurse on prenatal care. Which statement indicates that the client comprehends the nurse's instructions?

• A. I will increase my intake of vitamin C.
• B. I will avoid alcohol and tobacco.
• C. I will need to take folic acid supplements.
• D. I will avoid taking any medication without consulting my healthcare provider.

Correct answer: D

Rationale: The correct answer is D. During pregnancy, it is crucial to avoid taking any medication without consulting a healthcare provider to prevent harm to the developing fetus. Choices A, B, and C are important aspects of prenatal care but do not specifically address the potential risks associated with taking medications during pregnancy. Increasing intake of vitamin C (Choice A) is beneficial but does not address medication safety. Avoiding alcohol and tobacco (Choice B) is essential, but the question focuses on medication safety. Taking folic acid supplements (Choice C) is vital for neural tube development but does not cover the broader topic of medication safety.

3. The healthcare professional is preparing to administer a blood transfusion to a client with anemia. Which action is most important to prevent a transfusion reaction?

• A. Check the client's vital signs before starting the transfusion.
• B. Use a blood filter when administering the transfusion.
• C. Verify the blood type and Rh factor with another healthcare professional.
• D. Administer antihistamines before starting the transfusion.

Correct answer: C

Rationale: Verifying the blood type and Rh factor with another healthcare professional is the most crucial action to prevent a transfusion reaction. Ensuring compatibility between the donor blood and the recipient is essential in preventing adverse reactions such as hemolytic transfusion reactions. Checking vital signs is important for monitoring the client during the transfusion process but does not directly prevent a transfusion reaction. Using a blood filter can help remove clots and debris but does not address the risk of a reaction due to blood type incompatibility. Administering antihistamines before the transfusion is not a standard practice to prevent transfusion reactions related to blood type incompatibility.

4. The nurse is assessing a client with pneumonia. Which finding requires immediate intervention?

• A. Temperature of 99°F (37.2°C).
• B. Respiratory rate of 20 breaths per minute.
• C. Heart rate of 90 beats per minute.
• D. Fatigue.

Correct answer: C

Rationale: In a client with pneumonia, a heart rate of 90 beats per minute requires immediate intervention. Jugular vein distention indicates increased central venous pressure, suggesting possible complications like heart failure or fluid overload. Monitoring the heart rate closely and addressing any signs of heart failure promptly are crucial. A temperature of 99°F is within normal range and does not require immediate intervention. A respiratory rate of 20 breaths per minute is also normal. Fatigue is a common symptom in pneumonia but does not indicate an immediate need for intervention compared to the critical nature of jugular vein distention.

5. Which bioterrorism agent is at high risk for use as a potential biological weapon that is readily transmitted by several portals of entry?

• A. anthrax
• B. smallpox
• C. botulism
• D. tularemia

Correct answer: A

Rationale: Anthrax is the correct answer. Anthrax spores can be transmitted through inhalation, ingestion, or skin contact, making it a high-risk agent for bioterrorism. Smallpox, botulism, and tularemia are also potential bioterrorism agents, but they do not have the same versatility in terms of multiple portals of entry, unlike anthrax.

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