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. A 60-year-old male with type 2 diabetes mellitus tells the nurse that he is going to join a gym and start working out. Which information is most important for the nurse to obtain?

• A. Recent serum cholesterol levels
• B. Presence of calf pain during exercise
• C. Average weight gain or loss in the last year
• D. Exercise tolerance test with EKG results

Correct answer: B

Rationale: The most important information for the nurse to obtain in this scenario is the presence of calf pain during exercise. Calf pain during exercise could indicate peripheral vascular issues, such as peripheral artery disease, which is crucial to address before starting an exercise program. High cholesterol levels (choice A) may be important but are not as immediately relevant as assessing for peripheral vascular issues. Average weight gain or loss (choice C) may provide some insight into the patient's overall health status but is not as critical as assessing for potential vascular complications. An exercise tolerance test with EKG results (choice D) may be valuable in assessing cardiovascular fitness but is not as crucial as evaluating for peripheral vascular issues given the patient's symptoms.

3. An older male was recently admitted to the rehabilitation unit with unilateral neglect syndrome as a result of a cerebrovascular accident (CVA). Which action should the nurse include in the plan of care?

• A. Provide additional light in the room to promote sensory stimulation
• B. Teach the client to turn his head from side to side for visual scanning
• C. Place a clock and calendar in the room to improve orientation
• D. Use hand and arm gestures to improve communication and comprehension

Correct answer: B

Rationale: Teaching the client to turn his head from side to side for visual scanning is essential in addressing unilateral neglect syndrome caused by a cerebrovascular accident. This action helps improve visual awareness and assists the client in overcoming the neglect of one side of the body. Providing additional light for sensory stimulation (Choice A) may not directly address the issue of unilateral neglect. Placing a clock and calendar in the room (Choice C) may be helpful for orientation but does not specifically target unilateral neglect. Using hand and arm gestures for communication (Choice D) may aid in communication but does not directly address the visual scanning deficits associated with unilateral neglect syndrome.

4. While assessing a client four hours post-thoracentesis, the nurse is unable to auscultate breath sounds on the right side of the chest. What action should the nurse take first?

• A. Instruct the client to perform cough and deep breathing exercises
• B. Assess the client’s vital signs and respiratory effort
• C. Administer oxygen via nasal cannula according to the PNR protocol
• D. Document assessment findings in the client’s medical record

Correct answer: B

Rationale: The correct first action for the nurse to take in this situation is to assess the client’s vital signs and respiratory effort. It is crucial to promptly detect any immediate complications or changes in the client's condition. Instructing cough and deep breathing exercises (choice A) can be considered after further assessment. Administering oxygen (choice C) should be based on assessment findings and healthcare provider's orders. While documenting the findings (choice D) is essential, it should not be the first action when a potential issue with breath sounds is detected.

5. While a patient is receiving beta-1b interferon every other day for multiple sclerosis, which serum laboratory test findings should the nurse monitor to assess for possible bone marrow suppression caused by the medication? (Select all that apply)

• A. Platelet count
• B. White blood cell count (WBC)
• C. Sodium and potassium
• D. Red blood cell count (RBC)

Correct answer: A

Rationale: Beta-1b interferon can lead to bone marrow suppression, impacting blood cell production. Therefore, monitoring the platelet count, white blood cell count (WBC), and red blood cell count (RBC) is essential. Platelet count is a direct indicator of bone marrow function and can show early signs of bone marrow suppression. While sodium, potassium, and albumin/protein levels are important for overall health assessment, they are not directly associated with bone marrow suppression caused by the medication.

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