Nursing Elites

1. A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. Which assessment finding requires immediate intervention?

• A. Barrel-shaped chest
• B. Use of accessory muscles
• C. Oxygen saturation of 85%
• D. Inspiratory crackles

Correct answer: C

Rationale: An oxygen saturation of 85% is significantly low for a client with COPD and requires immediate intervention to prevent hypoxemia. Oxygen saturation below 90% indicates poor oxygenation and poses a risk of tissue hypoxia, making it a critical finding that needs prompt attention. Barrel-shaped chest and inspiratory crackles are commonly seen in clients with COPD and do not necessitate immediate intervention. The use of accessory muscles may indicate increased work of breathing but does not pose the same level of immediate threat as severe hypoxemia.

2. A client with a history of severe rheumatoid arthritis is receiving a corticosteroid. Which assessment finding should the nurse report to the healthcare provider immediately?

• A. Blood glucose level of 180 mg/dL
• B. Weight gain of 2 pounds in 24 hours
• C. Blood pressure of 140/90 mmHg
• D. Increased joint pain

Correct answer: C

Rationale: Elevated blood pressure (140/90 mmHg) is a significant finding that the nurse should report immediately. Hypertension can be a severe side effect of corticosteroid therapy, especially in clients with preexisting conditions like rheumatoid arthritis. It requires prompt intervention to prevent complications such as cardiovascular events. The other options, while important to monitor, are not as critical as elevated blood pressure in this context. A blood glucose level of 180 mg/dL may indicate hyperglycemia, weight gain could be due to fluid retention, and increased joint pain is expected in a client with severe rheumatoid arthritis.

3. A client with cirrhosis is admitted with hepatic encephalopathy. Which laboratory value requires immediate intervention?

• A. Serum ammonia level of 80 mcg/dl
• B. Bilirubin level of 3.0 mg/dl
• C. Serum sodium level of 135 mEq/L
• D. Prothrombin time of 18 seconds

Correct answer: D

Rationale: The correct answer is D. A prothrombin time of 18 seconds is most concerning in a client with hepatic encephalopathy as it indicates impaired liver function and an increased risk of bleeding. This requires immediate intervention to prevent bleeding complications. Choice A, serum ammonia level of 80 mcg/dl, is elevated but not as urgent as the abnormal prothrombin time. Choice B, bilirubin level of 3.0 mg/dl, is elevated but does not directly indicate an urgent need for intervention in this situation. Choice C, serum sodium level of 135 mEq/L, is within the normal range and does not require immediate intervention.

4. The nurse is assessing the thorax and lungs of a client who is experiencing respiratory difficulty. Which finding is most indicative of respiratory distress?

• A. Contractions of the sternocleidomastoid muscle.
• B. Respiratory rate of 20 breaths/min
• C. Downward movement of diaphragm with inspiration
• D. A pulse oximetry reading of SpO2 95%

Correct answer: A

Rationale: The correct answer is A: Contractions of the sternocleidomastoid muscle. Contractions of the sternocleidomastoid muscle suggest that the client is using accessory muscles to breathe, which is a clear sign of respiratory distress. This finding indicates that the client is working harder to breathe, typically seen in conditions like asthma, COPD, or respiratory failure. Choices B, C, and D are not the most indicative of respiratory distress. A respiratory rate of 20 breaths/min falls within the normal range. Downward movement of the diaphragm with inspiration is a normal finding indicating effective diaphragmatic breathing. A pulse oximetry reading of SpO2 95% is within the normal range and does not necessarily indicate respiratory distress.

5. A client with a spinal cord injury is admitted to the ICU. Which nursing intervention is most important to include in this client's plan of care?

• A. Monitor for signs of autonomic dysreflexia.
• B. Implement measures to prevent pressure ulcers.
• C. Perform passive range of motion exercises.
• D. Ensure that the client is turned every two hours.

Correct answer: A

Rationale: The correct answer is A: Monitor for signs of autonomic dysreflexia. Autonomic dysreflexia is a life-threatening condition that can occur in clients with spinal cord injuries, especially those with injuries above the T6 level. It is characterized by a sudden onset of excessively high blood pressure, pounding headache, profuse sweating, and flushing above the level of injury. Failure to recognize and treat autonomic dysreflexia promptly can lead to seizures, stroke, or even death. Therefore, monitoring for signs of autonomic dysreflexia is crucial in clients with spinal cord injuries. Choices B, C, and D are important interventions too, but in the context of a spinal cord injury, monitoring for autonomic dysreflexia takes priority due to its potentially life-threatening nature.

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