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 cirrhosis is admitted with hepatic encephalopathy. Which clinical finding is most concerning?

• A. Confusion and altered mental status
• B. Increased abdominal girth
• C. Yellowing of the skin
• D. Peripheral edema

Correct answer: A

Rationale: Confusion and altered mental status are the most concerning clinical findings in a client with hepatic encephalopathy. These symptoms indicate worsening liver function and potential neurological complications, requiring immediate medical attention. Increased abdominal girth may suggest ascites, yellowing of the skin can indicate jaundice, and peripheral edema may be related to fluid retention, but in the context of hepatic encephalopathy, confusion and altered mental status take precedence due to the risk of rapid deterioration and the need for prompt management.

3. A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear results are negative. What information should the nurse include in the client's teaching plan?

• A. Further evaluation involving surgery may be needed
• B. A pelvic exam is also needed before cancer is ruled out
• C. Pap smear evaluation should be continued every six months
• D. One additional negative Pap smear in six months is needed

Correct answer: A

Rationale: In a 60-year-old female client with a family history of ovarian cancer and an abdominal mass, further evaluation involving surgery may be needed to rule out ovarian cancer. The presence of an abdominal mass raises suspicion for a possible malignancy, and a negative Pap smear result does not rule out ovarian cancer. A pelvic exam alone may not provide sufficient information to confirm or rule out ovarian cancer. Continuing Pap smear evaluations every six months or waiting for one additional negative Pap smear in six months is not appropriate in this scenario, as the abdominal mass requires immediate attention and further evaluation.

4. A client with a history of chronic kidney disease (CKD) is receiving erythropoietin therapy. Which assessment finding is most concerning?

• A. Increased fatigue
• B. Headache
• C. Elevated blood pressure
• D. Low urine output

Correct answer: C

Rationale: In a client with chronic kidney disease receiving erythropoietin therapy, elevated blood pressure is the most concerning assessment finding. Erythropoietin can increase red blood cell production, leading to thicker blood, which in turn can elevate blood pressure. Elevated blood pressure in this scenario may indicate worsening hypertension, which requires prompt intervention to prevent complications such as stroke, heart attack, or further kidney damage. Increased fatigue (choice A) is a common symptom in CKD patients and can be expected with erythropoietin therapy. Headache (choice B) can occur but is less concerning than elevated blood pressure in this context. Low urine output (choice D) is a significant finding in CKD, but in a client receiving erythropoietin, elevated blood pressure takes precedence due to its potential for immediate adverse effects.

5. Progressive kyphoscoliosis leading to respiratory distress is evident in a client with muscular dystrophy. Which finding warrants immediate intervention by the nurse?

• A. Extremity muscle weakness.
• B. Bilateral eyelid drooping.
• C. Inability to swallow pills.
• D. Evidence of hypoventilation.

Correct answer: D

Rationale: The correct answer is D: Evidence of hypoventilation. In a client with muscular dystrophy and progressive kyphoscoliosis, hypoventilation indicates respiratory muscle weakness and can lead to life-threatening respiratory distress. Immediate intervention is crucial to prevent complications. Choices A, B, and C are incorrect because while extremity muscle weakness, bilateral eyelid drooping, and inability to swallow pills are concerning symptoms in muscular dystrophy, evidence of hypoventilation poses a more immediate threat to the client's respiratory status.

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