Nursing Elites

1. A healthcare provider assesses a client with pneumonia. Which clinical manifestation should the provider expect to find?

• A. Fremitus
• B. Hyperresonance
• C. Dullness on percussion
• D. Decreased tactile fremitus

Correct answer: C

Rationale: Pneumonia often leads to the consolidation of lung tissue, resulting in dullness on percussion. This occurs due to the presence of fluid or inflammatory material in the alveoli. Fremitus and decreased tactile fremitus are more indicative of conditions like pleural effusion or pneumothorax, where there is an increase in the density of the pleural space or air in the pleural cavity. Hyperresonance, on the other hand, is typically associated with conditions causing air trapping, such as emphysema, where there is increased air in the alveoli.

2. A client had an inferior wall myocardial infarction (MI). The nurse notes the client's cardiac rhythm as shown below. What action by the nurse is most important?

• A. Assess the client's blood pressure and level of consciousness.
• B. Call the health care provider or the Rapid Response Team.
• C. Obtain a permit for an emergency temporary pacemaker insertion.
• D. Prepare to administer antidysrhythmic medication.

Correct answer: A

Rationale: The ECG strip shows sinus bradycardia, which is common in clients with an inferior wall MI. This rhythm can lead to decreased perfusion due to bradycardia and blocks. The most crucial initial action for the nurse is to assess the client's hemodynamic status, including blood pressure and level of consciousness. This assessment will help determine the immediate needs of the client. Calling the health care provider or the Rapid Response Team, obtaining a permit for a pacemaker insertion, or preparing to administer antidysrhythmic medication may be necessary based on the assessment findings, but the priority is to evaluate the client's current condition first.

3. A client with a long history of smoking is being assessed by a nurse. Which finding is a common complication of chronic obstructive pulmonary disease (COPD)?

• A. Decreased anteroposterior chest diameter
• B. Increased breath sounds
• C. Prolonged expiratory phase
• D. Increased chest expansion

Correct answer: C

Rationale: In COPD, a prolonged expiratory phase is a typical finding caused by airway obstruction and air trapping. This results in difficulty expelling air from the lungs, leading to the characteristic prolonged exhalation in individuals with COPD.

4. A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client findings should the nurse intervene first?

• A. Urticaria
• B. Stridor
• C. Vomiting
• D. Hypotension

Correct answer: B

Rationale:

5. A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the client's face is puffy, and the eyelids are swollen. What action by the nurse takes priority?

• A. Assess the client's oxygen saturation.
• B. Notify the Rapid Response Team.
• C. Oxygenate the client with a bag-valve-mask.
• D. Palpate the skin of the upper chest.

Correct answer: A

Rationale: In this scenario, the client may have subcutaneous emphysema, where air leaks into the tissues surrounding the tracheostomy. The priority action for the nurse is to assess the client's oxygen saturation and other indicators of oxygenation to ensure adequate oxygen supply. If the client is stable, the nurse can then proceed to palpate the skin of the upper chest to check for subcutaneous emphysema. If the client is unstable, the nurse should promptly notify the Rapid Response Team. Using a bag-valve-mask device may be necessary for oxygenating the client, but assessing oxygen saturation comes first to guide further interventions.

Similar Questions