Nursing Elites

1. A client with chronic obstructive pulmonary disease (COPD) is experiencing shortness of breath and has a prescription for oxygen therapy. What is the maximum amount of oxygen the nurse should administer without a healthcare provider's order?

• A. 2 liters per minute
• B. 4 liters per minute
• C. 6 liters per minute
• D. 8 liters per minute

Correct answer: B

Rationale: The correct answer is 4 liters per minute. Without a healthcare provider's order, the nurse should administer a maximum of 4 liters per minute of oxygen to prevent carbon dioxide retention in COPD clients. Higher flow rates can lead to oxygen toxicity and worsen the client's condition. Choices A, C, and D exceed the safe limit for oxygen administration without a healthcare provider's order.

2. 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.

3. One day after abdominal surgery, an obese client complains of pain and heaviness in the right calf. What action should the nurse implement?

• A. Observe for unilateral swelling
• B. Administer pain medication
• C. Elevate the leg and apply a warm compress
• D. Notify the healthcare provider

Correct answer: A

Rationale: The correct action for the nurse to implement is to observe for unilateral swelling. Unilateral swelling could indicate a deep vein thrombosis (DVT), which is a serious complication that requires immediate assessment. Administering pain medication or applying warm compress may not address the underlying cause of the symptoms. Notifying the healthcare provider should be done after assessing and identifying the issue of unilateral swelling.

4. During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate first?

• A. Respiratory apnea of 30 seconds
• B. Oxygen saturation rate of 88%
• C. Eight premature ventricular beats every minute
• D. Disconnected monitor signal for the last 6 minutes.

Correct answer: A

Rationale: The correct answer is A: Respiratory apnea of 30 seconds. Respiratory apnea indicates a cessation of breathing, which is a life-threatening emergency requiring immediate intervention. Priority should be given to assessing and managing airway, breathing, and circulation. Option B, oxygen saturation rate of 88%, can indicate hypoxemia, but addressing the lack of breathing takes precedence. Option C, eight premature ventricular beats every minute, and option D, a disconnected monitor signal, are important but do not pose an immediate threat to the client's life compared to respiratory apnea.

5. Which breakfast selection indicates that the client understands the nurse's instructions about the dietary management of osteoporosis?

• A. Egg whites, toast, and coffee.
• B. Bran muffin, mixed fruits, and orange juice.
• C. Granola and grapefruit juice.
• D. Bagel with jelly and skim milk.

Correct answer: D

Rationale: The correct answer is D, 'Bagel with jelly and skim milk.' This choice includes skim milk, a good source of calcium, which is important for osteoporosis management. It also avoids foods that inhibit calcium absorption. Osteoporosis dietary management emphasizes increased calcium intake and reducing foods that hinder calcium absorption. Choice A only provides proteins but lacks calcium. Choice B offers fruits and a bran muffin, but it lacks a good source of calcium. Choice C has granola but misses a significant source of calcium.

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