Nursing Elites

1. During a home visit, a nurse sees a client with COPD receiving oxygen at 2 L/min through a nasal cannula. The client reports difficulty breathing. What is the priority nursing action at this time?

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

Correct answer: B

Rationale: The priority nursing action in this situation is to evaluate the client's respiratory status. When a client with COPD on oxygen therapy experiences difficulty breathing, the nurse should first assess the client's respiratory status to determine the severity of the situation. Increasing the oxygen flow without proper assessment can be harmful if not clinically indicated. While calling emergency services may eventually be necessary, it should not be the immediate action without assessing the client first. Instructing the client to cough and clear secretions is not appropriate as the nurse needs to evaluate the respiratory status before proceeding with interventions.

2. A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a myocardial infarction. While waiting for the laboratory to report the client's troponin levels, the client asks what this blood test will show. The nurse should explain that troponin is

• A. an enzyme that indicates damage to brain, heart, and skeletal muscle tissues.
• B. a protein whose levels reflect the risk for coronary artery disease.
• C. a heart muscle protein that appears in the bloodstream when there is damage to the heart.
• D. a protein that helps transport oxygen throughout the body.

Correct answer: C

Rationale: The correct answer is that troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart. Troponin is a specific marker for heart muscle damage, particularly seen in conditions like myocardial infarction. Choice A is incorrect as troponin is not an enzyme that indicates damage to brain and skeletal muscle tissues. Choice B is incorrect as troponin is not a protein whose levels reflect the risk for coronary artery disease; it indicates heart muscle damage. Choice D is incorrect as troponin is not a protein that helps transport oxygen throughout the body; its presence in the bloodstream is specific to heart muscle damage.

3. A client with peripheral arterial disease (PAD) is experiencing muscle pain or cramping during physical activity that resolves with rest. Which of the following symptoms is typically the initial reason clients with PAD seek medical attention?

• A. Intermittent claudication
• B. Dependent rubor
• C. Rest pain
• D. Foot ulcers

Correct answer: A

Rationale: The correct answer is Intermittent claudication. Intermittent claudication, which manifests as muscle pain or cramping during physical activity that improves with rest, is typically the initial reason clients with PAD seek medical attention. Dependent rubor, rest pain, and foot ulcers are more advanced symptoms of PAD and are not usually the initial reasons for seeking medical care.

4. A nurse in a community health center is assessing the results of the purified protein derivative (PPD) testing she performed to screen for tuberculosis (TB). She interprets which of the following results as positive for a 6-year-old client with no risk factors for TB?

• A. 4-mm erythema
• B. 5-mm induration
• C. 10-mm wheal
• D. 15-mm induration

Correct answer: D

Rationale: The correct answer is D: 15-mm induration. In PPD testing, an induration (hardened raised area) of 15 mm or more is considered positive for TB in individuals with no risk factors. Choices A, B, and C are incorrect because an erythema of 4 mm, induration of 5 mm, or wheal of 10 mm are not indicative of a positive TB test result in a low-risk individual. Therefore, the interpretation of a 15-mm induration would lead the nurse to consider the test positive for TB in this case.

5. A nurse is caring for a client who has active pulmonary tuberculosis (TB). The client is on airborne precautions and is being treated with multidrug therapy. A chest x-ray is scheduled for the client. Which of the following is not a precaution the nurse should take to safely transport the client to x-ray?

• A. Ask the x-ray technician to come to the client's room to perform a portable x-ray.
• B. Have the client wear a mask.
• C. Notify the x-ray department that the client is on airborne precautions.
• D. Wear a filtration mask and gloves for protection against the client's microorganisms.

Correct answer: A

Rationale: The correct answer is to ask the x-ray technician to come to the client's room to perform a portable x-ray. This option minimizes the risk of exposing other individuals to the client's infectious microorganisms during transport. Having the client wear a mask (Choice B) and notifying the x-ray department about airborne precautions (Choice C) are crucial precautions to prevent the spread of infection. Additionally, wearing a filtration mask and gloves (Choice D) is essential for the nurse's protection when in direct contact with the client, but it is not directly related to transporting the client to the x-ray department.

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