Nursing Elites

1. A female client is admitted with end-stage pulmonary disease, is alert, oriented, and complaining of shortness of breath. The client tells the nurse that she wants 'no heroic measures' taken if she stops breathing, and she asks the nurse to document this in her medical record. What action should the nurse implement?

• A. Ask the client to discuss 'do not resuscitate' with her healthcare provider
• B. Document the client's wishes in her medical record
• C. Ask the client to sign an advance directive
• D. Place a 'Do Not Resuscitate' (DNR) order in the client's chart

Correct answer: A

Rationale: The correct action for the nurse to implement is to ask the client to discuss 'do not resuscitate' (DNR) wishes with her healthcare provider. This is important to ensure that the client makes informed decisions regarding her care. While documenting the client's wishes in her medical record is essential, it is crucial that the client discusses these wishes with the healthcare provider to understand the implications and have the DNR order legally documented. Asking the client to sign an advance directive is premature without a detailed discussion with the healthcare provider. Placing a 'Do Not Resuscitate' (DNR) order in the client's chart should only be done after the client has discussed and agreed upon this decision with the healthcare provider.

2. An adolescent's mother calls the clinic because the teen is having recurrent vomiting and has been combative in the last 2 days. The mother states that the teen takes vitamins, calcium, and magnesium supplements along with aspirin. Which nursing intervention has the highest priority?

• A. Advise the mother to withhold all medications by mouth.
• B. Instruct the mother to take the teen to the emergency room.
• C. Recommend that the teen withhold food and fluids for 2 hours.
• D. Suggest that the adolescent breathe slowly and deeply.

Correct answer: B

Rationale: In this scenario, the highest priority nursing intervention is to instruct the mother to take the teen to the emergency room. The symptoms of recurrent vomiting, combative behavior, and the medications (vitamins, calcium, magnesium supplements, and aspirin) taken by the teen suggest a possible overdose or serious adverse reaction. Therefore, immediate medical evaluation is crucial to assess and manage any potential toxicity or adverse effects. Advising to withhold all medications by mouth (Choice A) may delay necessary treatment. Recommending withholding food and fluids for 2 hours (Choice C) may not address the underlying cause of the symptoms. Suggesting slow and deep breathing (Choice D) is not appropriate in this urgent situation requiring immediate medical attention.

3. A client with a history of myocardial infarction is experiencing chest pain. Which intervention should the nurse implement first?

• A. Administer oxygen therapy as prescribed.
• B. Administer aspirin as prescribed.
• C. Administer nitroglycerin sublingually as prescribed.
• D. Obtain an electrocardiogram (ECG).

Correct answer: A

Rationale: Administering oxygen therapy is the initial priority in managing chest pain in a client with a history of myocardial infarction. Oxygen therapy helps improve oxygenation, which is crucial in reducing myocardial damage. While administering aspirin and nitroglycerin are essential interventions in the treatment of myocardial infarction, oxygen therapy takes precedence because it addresses the immediate need for oxygen supply to the heart muscle. Obtaining an ECG is important but can be done after ensuring adequate oxygenation.

4. A male client with rheumatoid arthritis is scheduled for a procedure in the morning. The procedure cannot be completed due to early morning stiffness. Which intervention should the nurse implement?

• A. Assign a UAP to assist the client with a warm shower early in the morning.
• B. Administer anti-inflammatory medication before the procedure.
• C. Encourage the client to perform range-of-motion exercises.
• D. Reschedule the procedure for later in the day.

Correct answer: A

Rationale: A warm shower can help alleviate stiffness, allowing the client to be more comfortable and mobile before the procedure. This intervention promotes increased comfort and mobility, which may help the client proceed with the procedure later in the day. Administering anti-inflammatory medication (Choice B) may be helpful but may take time to be effective, while range-of-motion exercises (Choice C) may be challenging for the client due to stiffness. Rescheduling the procedure (Choice D) does not address the immediate need to alleviate stiffness.

5. 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.

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