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. A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs) for a client. Which statements should the nurse include in communications with the respiratory therapist prior to the tests? (SATA)

• A. I held the client's morning bronchodilator medication.
• B. The client is ready to go down to radiology for this examination.
• C. Physical therapy states the client can run on a treadmill.
• D. I advised the client not to smoke for 6 hours prior to the test.

Correct answer: B

Rationale: To ensure the PFTs are accurate, the therapist needs to know that no bronchodilators have been administered in the past 4 to 6 hours, the client did not smoke within 6 to 8 hours prior to the test and the client can follow basic commands, including different breathing maneuvers. The respiratory therapist can perform PFTs at the bedside. A treadmill is not used for this test.

3. A client has burns to his face, ears, and eyelids. What is the priority finding for the nurse to report to the provider?

• A. Urinary output of 25 mL/hr
• B. Difficulty swallowing
• C. Heart rate of 122/min
• D. Pain level of 6 on a scale of 0 to 10

Correct answer: B

Rationale: When a client has burns involving the face, ears, and eyelids, the priority finding to report to the provider is difficulty swallowing. This symptom could indicate potential airway compromise or swelling in the throat, which can lead to serious complications. Monitoring and addressing this issue promptly is crucial to ensure the client's airway remains patent and secure.

4. A client with chronic obstructive pulmonary disease (COPD) receives oxygen therapy. Which finding requires immediate intervention by the nurse?

• A. Oxygen saturation of 91%
• B. Respiratory rate of 10 breaths per minute
• C. Client reports shortness of breath
• D. Use of accessory muscles

Correct answer: B

Rationale: A respiratory rate of 10 breaths per minute in a client with COPD receiving oxygen therapy may indicate respiratory depression, necessitating immediate intervention. An oxygen saturation of 91%, client reports of shortness of breath, and use of accessory muscles are expected in COPD clients.

5. A client with chronic obstructive pulmonary disease (COPD) appears thin and disheveled. Which question should the nurse ask first?

• A. Do you have a strong support system?
• B. What do you understand about your disease?
• C. Do you experience shortness of breath with basic activities?
• D. What medications are you prescribed to take each day?

Correct answer: C

Rationale: In clients with severe COPD, shortness of breath can significantly impact their ability to perform basic activities like bathing and eating. Therefore, the nurse's priority should be to assess if shortness of breath is interfering with the client's basic activities, which can provide crucial information for planning and managing care.

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