Nursing Elites

1. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. Which assessment finding requires the nurse to take immediate action?

• A. Oxygen saturation of 90%
• B. Respiratory rate of 22 breaths per minute
• C. Client reports shortness of breath
• D. Client's respiratory rate decreases to 10 breaths per minute

Correct answer: D

Rationale: A decrease in the client's respiratory rate to 10 breaths per minute, while receiving oxygen therapy for COPD, is a concerning finding that may indicate carbon dioxide retention and respiratory depression. This situation requires immediate action to prevent further complications. An oxygen saturation of 90% is within an acceptable range for COPD patients on oxygen therapy. A respiratory rate of 22 breaths per minute and reports of shortness of breath are common in clients with COPD and may not necessitate immediate action unless accompanied by other concerning symptoms.

2. A client has returned from the surgical suite following surgery for a fractured mandible with intermaxillary fixation. Which of the following actions is the priority for the nurse to take?

• A. Prevent aspiration.
• B. Ensure adequate nutrition.
• C. Promote oral hygiene.
• D. Relieve the client's pain.

Correct answer: A

Rationale: Preventing aspiration is the priority for a client with intermaxillary fixation following mandibular surgery. Aspiration can occur due to difficulty swallowing or improper positioning, posing a serious risk to the client's respiratory status. It is crucial for the nurse to ensure that the client's airway is clear and that they are positioned correctly to prevent any potential aspiration events.

3. A client with chronic obstructive pulmonary disease is being taught by a nurse. Which nutritional information should the nurse include in the teaching? (SATA)

• A. Avoid drinking fluids just before and during meals.
• B. Rest before meals if you have dyspnea.
• C. Have about six small meals a day.
• D. Eat high-fiber foods to promote gastric emptying.

Correct answer: D

Rationale: In chronic obstructive pulmonary disease, it's important to consider the impact of nutrition on respiratory function. Eating high-fiber foods can lead to increased gas production, causing abdominal bloating and potentially worsening shortness of breath. Therefore, it is advisable for clients with COPD to avoid high-fiber foods to prevent these issues. Resting before meals can help manage dyspnea, and having smaller, more frequent meals can prevent bloating. Increasing calorie and protein intake is essential to prevent malnourishment in COPD patients. Additionally, limiting carbohydrate intake is crucial as it can increase carbon dioxide production, leading to a higher risk of acidosis in these individuals.

4. While caring for a client who was injured in a motor-vehicle crash and reports dyspnea and severe pain, a nurse in the emergency department notes that the client's chest moves inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following?

• A. Atelectasis
• B. Flail chest
• C. Hemothorax
• D. Pneumothorax

Correct answer: B

Rationale: Flail chest is characterized by paradoxical chest movement, where the chest moves inward during inspiration and bulges out during expiration. This occurs due to multiple rib fractures causing a segment of the chest wall to move independently from the rest of the thorax. Atelectasis refers to collapsed lung tissue, hemothorax is blood in the pleural space, and pneumothorax is air in the pleural space. In this scenario, the client's presentation aligns with the characteristic findings of flail chest.

5. A client with chronic obstructive pulmonary disease is being taught by a nurse about ways to facilitate eating. Which of the following statements indicates a need for further teaching?

• A. I will rest for at least 30 minutes before eating.
• B. I will take my bronchodilators after meals.
• C. I will eat five or six small meals each day.
• D. I will choose foods that are not gas-forming.

Correct answer: B

Rationale: Option B, 'I will take my bronchodilators after meals,' indicates a need for further teaching. Bronchodilators should be taken before meals to help open the airways and make breathing easier before eating. This statement suggests a misunderstanding of the timing for optimal bronchodilator effectiveness. Options A, C, and D are all appropriate strategies for facilitating eating for a client with chronic obstructive pulmonary disease.

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