Nursing Elites

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

• A. Increased oxygen saturation of 96%.
• B. Oxygen saturation of 89%.
• C. Respiratory rate of 20 breaths per minute.
• D. Decreased heart rate of 70 beats per minute.

Correct answer: B

Rationale: The correct answer is B. An oxygen saturation of 89% indicates hypoxemia, which is below the normal range (usually 95-100%). This finding requires immediate intervention as it signifies inadequate oxygenation. Options A, C, and D are within normal limits and do not indicate an urgent need for intervention. Option A indicates a good oxygen saturation level, option C denotes a normal respiratory rate, and option D suggests a normal heart rate. Therefore, these options do not require immediate intervention compared to the critically low oxygen saturation level of 89% in option B.

2. A male client with HIV on saquinavir and other antiretrovirals reports increased hunger and thirst but weight loss. Which action should the nurse take?

• A. Use a glucometer to assess capillary glucose.
• B. Explain to the client that an increased dose of medication is needed.
• C. Reassure the client that weight will improve as viral load decreases.
• D. Teach the client how to measure his weight accurately.

Correct answer: A

Rationale: Increased thirst and hunger while losing weight may indicate hyperglycemia, a common side effect of saquinavir and other antiretrovirals. Using a glucometer to assess capillary glucose levels is essential to evaluate for hyperglycemia. Choice B is incorrect because increasing the dose of medication without assessing blood glucose levels can be dangerous. Choice C is incorrect because weight loss may not necessarily improve with viral load reduction and doesn't address the immediate concern of hyperglycemia. Choice D is irrelevant to the presenting symptoms and should not be a priority over assessing for hyperglycemia.

3. A client is prescribed metformin for type 2 diabetes. What should the nurse emphasize in the client's teaching?

• A. Take the medication with meals to reduce the risk of GI upset.
• B. Report any muscle pain to the healthcare provider promptly.
• C. Avoid alcohol consumption while taking this medication.
• D. Monitor blood sugar levels regularly to prevent hypoglycemia.

Correct answer: C

Rationale: The correct answer is to avoid alcohol consumption while taking metformin. Alcohol can increase the risk of lactic acidosis when combined with metformin. Choice A is incorrect because metformin is usually recommended to be taken with meals to reduce GI upset. Choice B is important but not the priority; muscle pain is more commonly associated with other diabetes medications. Choice D is incorrect because metformin typically does not cause hypoglycemia but rather helps control blood sugar levels in type 2 diabetes.

4. A young male client is admitted to rehabilitation following a right above-knee amputation (AKA) and reports aching in his right foot. Which intervention is most important for the nurse to implement?

• A. Encourage discussion about feelings of limb loss.
• B. Administer a prescription for gabapentin.
• C. Teach the client how to wrap the stump with an elastic bandage.
• D. Offer assistance to move to a quiet room to relax.

Correct answer: B

Rationale: The correct answer is B: Administer a prescription for gabapentin. Gabapentin is used to treat phantom limb pain, which is common after amputations. Encouraging discussion about feelings of limb loss (choice A) is important for emotional support but does not address the physical pain. Teaching the client how to wrap the stump with an elastic bandage (choice C) is not indicated for aching in the 'right foot' as described. Offering assistance to move to a quiet room to relax (choice D) may provide comfort but does not address the underlying issue of phantom limb pain.

5. A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-drowning incident. While providing care to the child, the nurse begins talking with his preadolescent brother who rescued the child from the swimming pool and initiated resuscitation. The nurse notices the older boy becomes withdrawn when asked about what happened. Which action should the nurse take?

• A. Involve the older brother in supporting the child
• B. Ask the older brother how he felt during the incident
• C. Ask the parents for more information about the brother's behavior
• D. Reassure the brother that everything is fine now

Correct answer: B

Rationale: The older brother's withdrawal likely indicates emotional trauma or stress from the near-drowning event. Asking how he felt provides an opportunity for emotional support and allows the child to express feelings that may need addressing. Involving him in supporting the child may be overwhelming and not address his emotional needs directly. Asking the parents for more information may not allow the older brother to express his own feelings. Simply reassuring him that everything is fine now may dismiss his emotional experience without providing a chance for him to process his feelings.

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