Nursing Elites

1. A client with a history of chronic obstructive pulmonary disease (COPD) is admitted to the hospital. The client is experiencing difficulty breathing and is very anxious. The nurse notes that the client’s oxygen saturation is 88% on room air. Which action should the nurse implement first?

• A. Place the client in a high Fowler’s position
• B. Administer supplemental oxygen
• C. Perform a thorough respiratory assessment
• D. Start an IV infusion of normal saline

Correct answer: B

Rationale: Administering supplemental oxygen is the first priority to address low oxygen saturation and ease breathing. In a client with COPD experiencing difficulty breathing and anxiety with oxygen saturation at 88%, providing supplemental oxygen takes precedence over other actions. Placing the client in a high Fowler’s position may help with breathing but does not address the immediate need for increased oxygenation. Performing a thorough respiratory assessment is important but should come after stabilizing the client's oxygen levels. Starting an IV infusion of normal saline is not the priority in this situation and does not directly address the client's respiratory distress.

2. Four clients arrive on the labor and delivery unit at the same time. Which client should the nurse assess first?

• A. A 38-week primigravida who reports contractions occurring every 10 minutes
• B. A 39-week primigravida with a biophysical profile score of 5 out of 8
• C. A 41-week multigravida who is scheduled for induction of labor today
• D. A 36-week multigravida with a prescription for serial blood pressure

Correct answer: B

Rationale: The correct answer is B. A biophysical profile score of 5 out of 8 indicates potential fetal distress, necessitating immediate assessment to ensure the well-being of the fetus. The other options, while important, do not suggest an immediate threat to the fetus' health. The 38-week primigravida with contractions every 10 minutes may be in early labor, the 41-week multigravida scheduled for induction can be assessed after addressing the immediate concern, and the 36-week multigravida with serial blood pressure can be assessed after ensuring the client with potential fetal distress is stabilized.

3. After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wishes to see the body before it is taken to the funeral home. Which interventions should the nurse take to prepare the body before the family enters the room? (Select all that apply)

• A. Take out dentures and place them in a labeled cup
• B. Apply a body shroud
• C. Place a small pillow under the head
• D. Gently close the eyes

Correct answer: A

Rationale: The correct interventions for the nurse to prepare the body before the family enters the room include taking out dentures and placing them in a labeled cup. This is essential to ensure the dignity of the deceased and maintain their appearance. Applying a body shroud is not typically done before the family views the body, as it may be more appropriate during preparation for transportation to the funeral home. Placing a small pillow under the head and gently closing the eyes are actions that can be comforting but are not essential preparations for the family viewing.

4. The healthcare provider is completing a head-to-toe assessment for a client admitted for observation after falling out of a tree. Which finding warrants immediate intervention by the healthcare provider?

• A. Sluggish pupillary response to light
• B. Clear fluid leaking from the nose
• C. Complaint of severe headache
• D. Periorbital ecchymosis of the right eye

Correct answer: B

Rationale: Clear fluid leaking from the nose is concerning for cerebrospinal fluid leakage, which is a medical emergency requiring immediate intervention. Sluggish pupillary response to light may indicate neurological issues but is not as urgent as CSF leakage. Complaint of severe headache is important but not as critical as the possibility of CSF leakage. Periorbital ecchymosis of the right eye could be indicative of trauma but does not pose an immediate threat to the patient's life.

5. A client with rheumatoid arthritis reports a new onset of increasing fatigue. What intervention should the nurse implement first?

• A. Assist the client in conserving energy during daily activities
• B. Explain to the client that this could be a side effect of the medication
• C. Assess the client for pallor
• D. Encourage the client to maintain a balanced diet and hydration

Correct answer: C

Rationale: The correct first intervention for a client with rheumatoid arthritis reporting increasing fatigue is to assess the client for pallor. Fatigue can be a sign of anemia or other complications; assessing for pallor can help determine if anemia is the cause. Option A is incorrect as it does not address the underlying cause of fatigue. Option B assumes the cause without further assessment. Option D is important for overall health but assessing for pallor takes precedence to identify immediate issues related to fatigue.

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