Nursing Elites

1. A client with pneumonia is receiving oxygen via nasal cannula at 2 L/min. What assessment finding indicates the need for further intervention?

• A. The client reports feeling short of breath.
• B. The client's oxygen saturation is 92%.
• C. The client's respiratory rate is 20 breaths per minute.
• D. The client is unable to complete sentences without pausing.

Correct answer: D

Rationale: The correct answer is D because the inability to complete sentences without pausing indicates respiratory distress and the need for immediate intervention. This finding suggests an increased work of breathing and inadequate oxygenation. Choices A, B, and C are not as urgent as choice D. Feeling short of breath (choice A) is expected in pneumonia but does not necessarily indicate the need for immediate intervention. An oxygen saturation of 92% (choice B) is slightly below the normal range but may not require immediate intervention. A respiratory rate of 20 breaths per minute (choice C) is within the normal range and does not signify an urgent need for intervention.

2. A client with a seizure disorder is prescribed phenytoin. What is the most important teaching the nurse should provide?

• A. Take phenytoin with antacids to reduce stomach upset.
• B. Maintain a consistent dosing schedule to prevent seizures.
• C. Monitor for excessive drowsiness and dizziness.
• D. Take the medication at bedtime to reduce seizure risk.

Correct answer: B

Rationale: The most important teaching the nurse should provide to a client prescribed phenytoin is to maintain a consistent dosing schedule to prevent seizures. Phenytoin is an antiepileptic drug, and missing doses can increase the risk of seizures. Option A is incorrect because antacids can interact with phenytoin and reduce its absorption. Option C is important but not the most critical teaching as compared to maintaining a consistent dosing schedule. Option D is incorrect because the timing of phenytoin administration should be consistent rather than specifically at bedtime.

3. A client is admitted with a suspected gastrointestinal bleed. What assessment finding requires immediate intervention?

• A. Bright red blood in the vomit.
• B. Elevated blood pressure and heart rate.
• C. Coffee ground emesis.
• D. Dark, tarry stools.

Correct answer: D

Rationale: Dark, tarry stools indicate the presence of digested blood in the gastrointestinal tract, signifying a higher gastrointestinal bleed. This finding requires immediate intervention due to the potential severity of the bleed. Bright red blood in the vomit may indicate active bleeding but is not as concerning as digested blood. Elevated blood pressure and heart rate are common responses to bleeding but do not provide direct evidence of the source or severity of the bleed. Coffee ground emesis is indicative of partially digested blood and is a concern but not as urgent as dark, tarry stools.

4. An older male client, who is a retired chef, is hospitalized with a diabetic ulcer on his foot. His daughter tells the nurse that her father has become increasingly obsessed with the way his food is prepared in the hospital. The nurse's response should be based on what information?

• A. His daughter's observations suggest the client is depressed
• B. His compulsiveness about food may indicate new cognitive decline
• C. Obsessiveness with food is common in diabetic clients
• D. If the client was compulsive about food when he was younger, the aging process can magnify this

Correct answer: D

Rationale: Age can magnify pre-existing compulsive tendencies. If the client was detail-oriented about food earlier in life, this behavior may intensify with aging. It's important to acknowledge and address the client's concerns respectfully. Choices A, B, and C are incorrect because the daughter's observations do not necessarily point to depression, the compulsiveness about food does not indicate new cognitive decline without further assessment, and obsessiveness with food is not specifically common in diabetic clients.

5. Which strategy should the nurse implement when teaching a client with low literacy about a new diagnosis of hypertension?

• A. Provide a detailed handout with complex terms
• B. Use simple language and visual aids
• C. Encourage the client to research the diagnosis online
• D. Incorporate medical jargon to explain the condition

Correct answer: B

Rationale: The correct strategy for teaching a client with low literacy about a new diagnosis of hypertension is to use simple language and visual aids. This approach helps ensure better understanding of the diagnosis and treatment plan by making the information clear and accessible. Providing a detailed handout with complex terms (Choice A) would not be suitable as it may confuse the client further. Encouraging the client to research the diagnosis online (Choice C) could lead to misinformation and overwhelm the client with information they may not understand. Incorporating medical jargon to explain the condition (Choice D) would not be helpful for a client with low literacy as it may complicate rather than clarify the information.

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