Nursing Elites

1. A healthcare professional auscultates a harsh hollow sound over a client's trachea & larynx. Which action should the healthcare professional take first?

• A. Document findings.
• B. Administer O2 therapy.
• C. Position client in high-Fowler's position.
• D. Administer prescribed albuterol.

Correct answer: A

Rationale: The healthcare professional has identified bronchial breath sounds, which are normal findings over the trachea & larynx, characterized by harsh, hollow, tubular, and blowing sounds. The appropriate initial action for the healthcare professional is to document these normal findings. Oxygen therapy, administering albuterol, or repositioning the client is unnecessary as this finding does not indicate a need for intervention.

2. During an admission assessment of a client with COPD and emphysema complaining of a frequent productive cough and shortness of breath, what assessment finding should the nurse anticipate?

• A. Respiratory alkalosis
• B. Increased anteroposterior diameter of the chest
• C. Oxygen saturation level 96%
• D. Petechiae on chest

Correct answer: B

Rationale: COPD and emphysema are chronic respiratory conditions that can lead to changes in the shape of the chest. In clients with COPD, the anteroposterior diameter of the chest often increases, giving a barrel chest appearance. This change in chest shape is due to hyperinflation of the lungs and is a common physical finding in clients with COPD and emphysema. The other options are not typically associated with COPD and emphysema. Respiratory alkalosis is not a common finding in these clients. An oxygen saturation level of 96% is within the normal range and does not specifically relate to COPD. Petechiae on the chest are not typically associated with COPD or emphysema.

3. A client had a bronchoscopy 2 hours ago and asks for a drink of water. Which action should the nurse take next?

• A. Call the healthcare provider to request a prescription for food and water.
• B. Provide the client with ice chips instead of a drink of water.
• C. Assess the client's gag reflex before giving any food or water.
• D. Let the client have a small sip to assess swallowing ability.

Correct answer: C

Rationale: After a bronchoscopy, a topical anesthetic affects the gag reflex. Therefore, the nurse should assess the client's gag reflex before providing any food or water to ensure its return. This assessment is crucial to prevent aspiration or choking risk in the client.

4. A client in the emergency department is being cared for by a nurse and has cardiogenic pulmonary edema. The client's assessment findings include anxiousness, dyspnea at rest, crackles, blood pressure 110/79 mm Hg, and apical heart rate 112/min. What is the nurse's priority intervention?

• A. Provide the client with supplemental oxygen at 5 L/min via facemask.
• B. Place the client in high-Fowler's position with their legs in a dependent position
• C. Give the client sublingual nitroglycerin
• D. Administer morphine sulfate IV

Correct answer: A

Rationale: In cardiogenic pulmonary edema, the priority intervention is to improve oxygenation and reduce the workload on the heart. Providing supplemental oxygen at 5 L/min via facemask helps increase oxygen levels and alleviate respiratory distress. This intervention can help improve oxygen saturation, alleviate dyspnea, and support the client's respiratory function. Placing the client in a high-Fowler's position with legs dependent can also help with respiratory effort, but ensuring adequate oxygenation takes precedence. Sublingual nitroglycerin and IV morphine sulfate are commonly used interventions for cardiac-related conditions, but in this case, addressing oxygenation is the priority to prevent further deterioration.

5. A healthcare professional is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the healthcare professional expect?

• A. Bradycardia
• B. Bradypnea
• C. Lethargy
• D. Intercostal retractions

Correct answer: D

Rationale: Postoperative atelectasis can lead to hypoxia, which causes respiratory distress. Intercostal retractions, where the muscles between the ribs pull inward during inspiration, are a common sign of respiratory distress in a client with atelectasis. Bradycardia (slow heart rate), Bradypnea (slow breathing rate), and lethargy are not typically associated with atelectasis and hypoxia.

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