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. When performing tracheostomy care, which intervention should the nurse implement?

• A. Use aseptic technique.
• B. Clean the inner cannula with mild soap and water.
• C. Secure new tracheostomy ties before removing old ones.
• D. Apply suction when inserting the catheter.

Correct answer: C

Rationale: When caring for a client with a tracheostomy, it is essential to ensure that the airway is maintained and secured at all times. Securing new tracheostomy ties before removing the old ones helps prevent accidental decannulation and ensures continuous airway patency. Aseptic technique is crucial to prevent infections but is not directly related to securing the tracheostomy ties. Cleaning the inner cannula with mild soap and water is important for maintaining hygiene but does not address the immediate need for securing the airway. Applying suction when inserting the catheter is not a standard practice during tracheostomy care.

3. When teaching a client with chronic obstructive pulmonary disease who will start using fluticasone via MDI twice daily, which instruction should the nurse include?

• A. Monitor your heart rate before each dose.
• B. Inspect your mouth for lesions daily.
• C. Do not use this medication to relieve an acute attack.
• D. Do not skip the morning dose even if symptom-free.

Correct answer: B

Rationale: It is crucial for clients using inhaled corticosteroids like fluticasone to inspect their mouths daily for signs of oral thrush, a common side effect. Checking the mouth can help identify lesions early, allowing for timely intervention to prevent worsening of the condition. Monitoring heart rate is not specifically required for this medication. Fluticasone is a maintenance medication used to manage COPD, not to relieve acute attacks. Skipping doses, especially in the morning, can lead to inadequate control of COPD symptoms.

4. A healthcare professional is assessing a client who has a fracture of the femur. Vital signs are obtained on admission and again in 2 hours. Which of the following changes in assessment should indicate to the healthcare professional that the client could be developing a serious complication?

• A. Increased respiratory rate from 18 to 44/min
• B. Increased oral temperature from 36.6� C (97.8� F) to 37� C (98.6� F)
• C. Increased blood pressure from 112/68 to 120/72 mm Hg
• D. Increased heart rate from 68 to 72/min

Correct answer: A

Rationale: An increased respiratory rate from 18 to 44/min is a significant change that should alert the healthcare professional to a potential serious complication. Such a drastic increase in respiratory rate may indicate respiratory distress or hypoxia, which are critical conditions requiring immediate attention. The other options show minor changes in vital signs that are within normal limits and are less likely to indicate a serious complication.

5. A healthcare professional is monitoring a client following a thoracentesis. The healthcare professional should identify which of the following manifestations as a complication and contact the provider immediately?

• A. Serosanguineous drainage from the puncture site
• B. Discomfort at the puncture site
• C. Increased heart rate
• D. Decreased temperature

Correct answer: C

Rationale: Following a thoracentesis, it is crucial for healthcare professionals to monitor for potential complications. Increased heart rate can indicate hypovolemia or other serious issues, such as bleeding or pneumothorax, and requires immediate attention to prevent further complications. Serosanguineous drainage from the puncture site is a common expected finding post-procedure. Discomfort at the puncture site is also common and can be managed with appropriate interventions. Decreased temperature is not typically associated with complications following a thoracentesis. Therefore, the correct answer is increased heart rate as it signifies a potential serious complication that needs prompt medical evaluation.

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