Nursing Elites

1. A client with emphysema is being assessed by a nurse. Which clinical manifestation should the nurse expect?

• A. Decreased chest expansion
• B. Cyanosis
• C. Pursed-lip breathing
• D. Bradypnea

Correct answer: C

Rationale: Pursed-lip breathing is a common manifestation in clients with emphysema. It helps to increase the duration of exhalation and reduce air trapping, aiding in the management of the condition. Decreased chest expansion and bradypnea are not typically associated with emphysema. While cyanosis can occur in severe cases, pursed-lip breathing is a more specific and commonly observed sign of emphysema.

2. While caring for a client using O2 in the hospital, what assessment finding indicates that goals for a priority diagnosis are being met?

• A. 100% of meals being eaten by the client
• B. Intact skin behind the ears
• C. The client understanding the need for oxygen
• D. Unchanged weight for the past 3 days

Correct answer: B

Rationale: When a client is using oxygen, there is a risk for impaired skin integrity due to pressure from tubing. Intact skin behind the ears suggests that the client is not experiencing skin breakdown, meeting the goals for this diagnosis. The client's nutrition, understanding of oxygen therapy, and weight stability are important but do not directly relate to the priority diagnosis of skin integrity in this context.

3. A client has a pulmonary embolism & is started on oxygen. The student nurse asks why the client's oxygen saturation has not significantly improved. What response by the nurse is best?

• A. Breathing so rapidly interferes with oxygenation.
• B. Maybe the client has respiratory distress syndrome.
• C. The blood clot interferes with perfusion in the lungs.
• D. The client needs immediate intubation & mechanical ventilation.

Correct answer: C

Rationale: A large blood clot in the lungs will significantly impair gas exchange & oxygenation. Unless the clot is dissolved, this process will continue unabated.

4. A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active, and has no known risk factors for PE. What action by the nurse is most appropriate?

• A. Encourage the client to walk for 5 minutes each hour.
• B. Refer the client for smoking cessation classes.
• C. Teach the client about factor V Leiden testing.
• D. Explain to the client that sometimes no cause for the disease is found.

Correct answer: C

Rationale: The most appropriate action for the nurse in this scenario is to teach the client about factor V Leiden testing. Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting events, including pulmonary embolism (PE). In a case where a client has no known risk factors for PE, testing for this genetic disorder is crucial to determine if it is a contributing factor. Encouraging the client to walk or referring them to smoking cessation classes, while beneficial for overall health, are not directly relevant to the development of a PE in this specific case. While it is true that sometimes no cause for a disease is found, prematurely assuming this without appropriate investigations may lead to missed opportunities for preventive measures or treatments.

5. A client is on intravenous heparin to treat a pulmonary embolism. The client's most recent partial thromboplastin time (PTT) was 25 seconds. What action should the nurse anticipate?

• A. Decrease the heparin rate.
• B. Increase the heparin rate.
• C. No change to the heparin rate.
• D. Stop the heparin; start warfarin (Coumadin).

Correct answer: B

Rationale: For clients on heparin therapy, a PTT value of 1.5 to 2.5 times the normal range is required to ensure therapeutic anticoagulation. The normal PTT range is 25 to 35 seconds. In this case, the client's PTT of 25 seconds falls below the therapeutic range, indicating that the heparin dose is insufficient. Therefore, the nurse should anticipate increasing the heparin rate to achieve the desired therapeutic effect.

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