Nursing Elites

1. A client with pneumonia is receiving antibiotics and oxygen therapy. What assessment finding requires immediate intervention?

• A. Productive cough with yellow sputum.
• B. Oxygen saturation of 88%.
• C. Respiratory rate of 20 breaths per minute.
• D. Heart rate of 90 beats per minute.

Correct answer: B

Rationale: An oxygen saturation of 88% indicates hypoxemia, which is a critical condition requiring immediate intervention to improve oxygenation. Hypoxemia can lead to tissue hypoxia and further complications. A productive cough with yellow sputum is common in pneumonia but may not require immediate intervention unless it worsens or is associated with other concerning symptoms. A respiratory rate of 20 breaths per minute is within the normal range, indicating adequate ventilation. A heart rate of 90 beats per minute is also within a normal range and may not require immediate intervention unless it is accompanied by other abnormal findings.

2. A young adult visits the clinic reporting symptoms associated with gastritis. Which information in the client's history is most important for the nurse to address in the teaching plan?

• A. Experiences occasional heartburn after eating spicy food
• B. Consumes 10 or more drinks of alcohol every weekend
• C. Reports frequent use of NSAIDs
• D. Has a history of peptic ulcers

Correct answer: B

Rationale: Excessive alcohol consumption is a major risk factor for gastritis and should be prioritized in the teaching plan. While spicy foods and NSAIDs can contribute to gastritis, alcohol consumption is the most significant factor that needs immediate lifestyle changes to prevent worsening of gastritis symptoms. Peptic ulcers, although relevant, are not as directly linked to exacerbating gastritis symptoms as alcohol consumption.

3. The nurse is caring for a 24-month-old toddler who has sensory sensitivity, difficulty engaging in social interactions, and has not yet spoken two-word phrases. Which assessment should the nurse administer?

• A. Peabody Picture Vocabulary Test
• B. The Modified Checklist for Autism in Toddlers (M-CHAT)
• C. Wechsler Preschool and Primary Scale of Intelligence
• D. Denver Developmental Screening Test

Correct answer: B

Rationale: The Modified Checklist for Autism in Toddlers (M-CHAT) is specifically designed to screen for autism spectrum disorders in young children. It is appropriate for this child, given the signs of social and communication delays. The Peabody Picture Vocabulary Test (Choice A) assesses receptive vocabulary and may not capture the social and communication aspects seen in autism. The Wechsler Preschool and Primary Scale of Intelligence (Choice C) measures cognitive ability and may not address the social and communication delays. The Denver Developmental Screening Test (Choice D) is a broad developmental assessment tool, but the M-CHAT is more specific to screening for autism in this case.

4. The nurse assesses a 72-year-old client who was admitted for right-sided congestive heart failure. Which of the following would the nurse anticipate finding?

• A. Decreased urinary output
• B. Jugular vein distention
• C. Pleural effusion
• D. Bibasilar crackles

Correct answer: B

Rationale: Correct! In right-sided congestive heart failure, jugular vein distention is a common finding due to the backup of blood in the systemic circulation. This results in increased venous pressure, leading to jugular vein distention. Choices A, C, and D are incorrect because decreased urinary output, pleural effusion, and bibasilar crackles are more commonly associated with other conditions such as kidney dysfunction, lung issues, and pulmonary edema.

5. The nurse is preparing to administer a subcutaneous injection to a thin, elderly client. What is the most appropriate site for the injection?

• A. Dorsal aspect of the upper arm.
• B. Upper outer thigh.
• C. Lower abdomen.
• D. Lateral aspect of the upper arm.

Correct answer: B

Rationale: The correct answer is the upper outer thigh. In thin, elderly clients, the upper outer thigh is a recommended site for subcutaneous injections due to the presence of adequate subcutaneous tissue and muscle mass. The dorsal aspect of the upper arm may not provide enough subcutaneous tissue for proper absorption of the medication. The lower abdomen is not ideal for thin individuals as it may lead to injection into muscle rather than subcutaneous tissue. The lateral aspect of the upper arm is also not a commonly recommended site for subcutaneous injections.

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