Nursing Elites

1. A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Which assessment finding is most concerning to the nurse?

• A. Oxygen saturation of 90%
• B. Respiratory rate of 24 breaths per minute
• C. Use of accessory muscles
• D. Inspiratory crackles

Correct answer: C

Rationale: The correct answer is C: 'Use of accessory muscles.' In a client with a history of COPD, the use of accessory muscles indicates increased work of breathing and may signal respiratory failure, necessitating immediate intervention. This finding is concerning as it suggests the client is struggling to breathe adequately. Oxygen saturation of 90% (choice A) is low but may be expected in COPD patients; it requires monitoring and intervention but is not as immediately concerning as the use of accessory muscles. A respiratory rate of 24 breaths per minute (choice B) is within a normal range and, although slightly elevated, may be a typical response to pneumonia. Inspiratory crackles (choice D) can be a common finding in pneumonia and are not as indicative of impending respiratory failure as the use of accessory muscles.

2. An adult male who lives alone is brought to the Emergency Department by his daughter. He is unresponsive, with minimal respiratory effort, and his pupils are fixed and dilated. At the daughter's request, the client is intubated and mechanically ventilated. Which nursing intervention has the highest priority?

• A. Offer to notify the client's minister of his condition.
• B. Determine if the client has an executed living will.
• C. Provide the family with information about palliative care.
• D. Explore the possibility of organ donation with the family.

Correct answer: B

Rationale: The highest priority nursing intervention in this scenario is to determine if the client has an executed living will. A living will provides guidance on the client's preferences for medical care in situations where they cannot communicate. This information is crucial in guiding the care team on how to proceed with treatment. Options A, C, and D, though important in certain circumstances, are not the highest priority in this situation where immediate decisions regarding the client's care need to be made.

3. After receiving lactulose, a client with hepatic encephalopathy has several loose stools. What action should the nurse implement?

• A. Send stool specimen to the lab
• B. Measure abdominal girth
• C. Encourage increased fiber in the diet
• D. Monitor mental status

Correct answer: D

Rationale: The correct action for the nurse to implement after a client with hepatic encephalopathy has loose stools following lactulose administration is to monitor the client's mental status. Lactulose is given to lower serum ammonia levels in hepatic encephalopathy, and loose stools can be an expected side effect of its use. Monitoring mental status is crucial because changes in mental status, such as confusion or altered level of consciousness, are key indicators of hepatic encephalopathy worsening. Sending a stool specimen to the lab would not be the priority in this situation as loose stools are a known effect of lactulose. Measuring abdominal girth is more relevant for conditions like ascites, not loose stools. Encouraging increased fiber in the diet may be beneficial for constipation but is not the immediate action needed when loose stools occur after lactulose administration.

4. A male client with hypertension, who received new antihypertensive prescriptions at his last visit, returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106, and he admits that he has not been taking the prescribed medication because the drugs make him 'feel bad'. In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?

• A. Blindness due to cataracts
• B. Acute kidney injury due to glomerular damage
• C. Stroke secondary to hemorrhage
• D. Heart block due to myocardial damage

Correct answer: C

Rationale: The correct answer is C, 'Stroke secondary to hemorrhage.' Uncontrolled hypertension can lead to the weakening of blood vessels in the brain, increasing the risk of a stroke due to hemorrhage. This can result in serious neurological deficits or even death. Choices A, B, and D are incorrect because while hypertension can have various complications including vision changes, kidney damage, and heart problems, the most immediate and severe risk associated with uncontrolled hypertension is a stroke from cerebral hemorrhage.

5. In determining the client position for insertion of an indwelling urinary catheter, it is most important for the nurse to recognize which client condition?

• A. High urinary pH
• B. Abdominal ascites
• C. Orthopnea
• D. Fever

Correct answer: C

Rationale: The correct answer is C: Orthopnea. If the client is orthopneic, the nurse needs to adapt the insertion position that does not place the client in a supine position. This means the head of the bed should be elevated as much as possible to facilitate catheter insertion without compromising the client's breathing. High urinary pH (choice A) is not directly relevant to the insertion position of a urinary catheter. Abdominal ascites (choice B) may impact the procedure due to abdominal distension but is not as crucial as orthopnea. Fever (choice D) does not specifically affect the client's position for urinary catheter insertion.

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