Nursing Elites

1. A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse's priority?

• A. Increase the oxygen flow to 3 L/min.
• B. Assess the client's respiratory status.
• C. Call emergency services for the client.
• D. Have the client cough and expectorate secretions.

Correct answer: B

Rationale: When a client with COPD on oxygen therapy reports difficulty breathing, the priority action for the nurse is to assess the client's respiratory status. This involves evaluating the client's oxygen saturation levels, respiratory rate, effort of breathing, lung sounds, and overall respiratory distress. By assessing the client's respiratory status, the nurse can determine the severity of the situation and make appropriate decisions regarding further interventions, such as adjusting oxygen flow rate, providing respiratory treatments, or seeking emergency assistance if necessary.

2. When a client develops an airway obstruction from a foreign body but remains conscious, which of the following actions should the nurse take first?

• A. Insert an oral airway
• B. Administer the abdominal thrust maneuver
• C. Turn the client to the side
• D. Perform a blind finger sweep

Correct answer: B

Rationale: When a client develops an airway obstruction and remains conscious, the nurse's initial action should be to administer the abdominal thrust maneuver. This technique, also known as the Heimlich maneuver, can help dislodge the obstructing object and clear the airway. Inserting an oral airway, turning the client to the side, or performing a blind finger sweep are not recommended as the first interventions for a conscious individual with an airway obstruction.

3. A client with heart failure has gained 2 kg (4.4 lbs) in the past 24 hours. What action should the nurse take first?

• A. Restrict the client's fluid intake.
• B. Assess the client's respiratory status.
• C. Administer diuretics as ordered.
• D. Notify the healthcare provider.

Correct answer: B

Rationale: Assessing the client's respiratory status is the priority as it helps determine if the weight gain is due to fluid retention affecting breathing. This assessment is crucial in addressing the immediate concern of potential respiratory distress before implementing interventions like fluid restriction, diuretics, or notifying the healthcare provider.

4. A client with acute respiratory distress syndrome (ARDS) requires care planning. Which of the following interventions should be included in the plan?

• A. Administer low-flow oxygen continuously via nasal cannula.
• B. Encourage oral intake of at least 3,000 mL of fluids per day.
• C. Offer high-protein and high-carbohydrate foods frequently.
• D. Place in a prone position

Correct answer: D

Rationale: In acute respiratory distress syndrome (ARDS), placing the client in a prone position helps improve ventilation-perfusion matching and oxygenation. This position can optimize lung function and is a beneficial intervention for clients with ARDS. Administering low-flow oxygen via nasal cannula, encouraging oral intake of excess fluids, or offering high-protein and high-carbohydrate foods are not primary interventions for ARDS and may not directly address the respiratory distress experienced by the client.

5. While suctioning the endotracheal tube of a client on a ventilator, the nurse notices an increase in the client's heart rate from 86/min to 110/min, with irregularity. What should the nurse do next?

• A. Obtain a cardiology consult.
• B. Suction the client less frequently.
• C. Administer an antidysrhythmic medication.
• D. Perform pre-oxygenation prior to suctioning.

Correct answer: D

Rationale: When a client's heart rate increases and becomes irregular during suctioning of an endotracheal tube, it indicates potential hypoxemia. Performing pre-oxygenation before suctioning helps prevent hypoxemia and subsequent dysrhythmias. This intervention ensures that the client has adequate oxygen reserves before the procedure, reducing the risk of complications related to suctioning.

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