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. When administering ceftriaxone sodium intravenously to a client before surgery, which assessment finding requires the most immediate intervention by the nurse?

• A. Headache
• B. Pruritus
• C. Nausea
• D. Stridor

Correct answer: D

Rationale: Stridor is a high-pitched, noisy breathing sound that can indicate a serious condition like airway obstruction or a severe allergic reaction, necessitating immediate intervention to maintain the client's airway and prevent further complications. While headache, pruritus, and nausea are important to assess and manage, they are not as immediately life-threatening as stridor, which requires prompt attention to prevent respiratory compromise.

3. The nurse administers an oral antiviral to a client with shingles. Which finding is most important for the nurse to report to the healthcare provider?

• A. Decreased white blood cell count
• B. Pruritus and muscle aches
• C. Elevated liver function tests
• D. Vomiting and diarrhea

Correct answer: C

Rationale: The correct answer is C: Elevated liver function tests. When administering antivirals, especially orally, monitoring liver function tests is crucial as it may indicate liver toxicity. This finding should be reported promptly to the healthcare provider to prevent further complications. Choice A, decreased white blood cell count, may be expected with certain antivirals but is not the most critical finding in this scenario. Pruritus and muscle aches (choice B) are common side effects of antivirals and do not require immediate reporting. Vomiting and diarrhea (choice D) are also common side effects that may not be as concerning as elevated liver function tests.

4. While caring for a client with bilateral chest tubes, the bubbling in the water-seal chamber of the right chest tube stops. What action is most important for the nurse to take?

• A. Check the chest tube connections to the water-seal container
• B. Replace the water-seal collection container
• C. Increase the amount of wall suction connected to the right chest tube
• D. Milk the tubing connected to the right chest tube

Correct answer: A

Rationale: The most important action for the nurse to take when the bubbling in the water-seal chamber of the right chest tube stops is to check the chest tube connections to the water-seal container. This is crucial to ensure there are no disconnections or leaks affecting the bubbling. Replacing the water-seal collection container (choice B) is not necessary unless there is a malfunction; increasing suction (choice C) without assessing the connections can be harmful, and 'milking' the tubing (choice D) is an inappropriate action that can cause damage to the system.

5. A male client with schizophrenia tells the nurse that the hospital has installed cameras that watch him and listening devices that record what everyone says. Which nursing problem should the nurse document for this client?

• A. Noncompliance with medication related to thought broadcasting
• B. Situational self-esteem disturbance secondary to schizophrenia
• C. Disturbed sensory perception related to auditory hallucinations
• D. Impaired environmental interpretation related to paranoid delusions

Correct answer: D

Rationale: The correct answer is D: Impaired environmental interpretation related to paranoid delusions. The client's belief about cameras watching and recording him is a manifestation of paranoid delusions, indicating a misinterpretation of the environment. Choice A is incorrect because thought broadcasting is not directly related to the client's belief about surveillance equipment. Choice B is incorrect as self-esteem disturbance is not the primary issue presented. Choice C is also incorrect as the client is not experiencing auditory hallucinations but rather paranoid delusions about surveillance.

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