Nursing Elites

1. A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

• A. Insert an indwelling urinary catheter.
• B. Inspect the mouth for signs of inhalation injuries.
• C. Administer intravenous pain medication.
• D. Draw blood for a complete blood cell (CBC) count.

Correct answer: B

Rationale: When caring for a client with burns, especially burns to the face and chest, the priority action for the nurse is to inspect the mouth for signs of inhalation injuries. Inhalation injuries can be life-threatening and may not be immediately apparent. Identifying these injuries early allows for prompt intervention and can significantly impact the client's outcomes. While other actions such as pain management and blood tests are important, assessing for inhalation injuries takes precedence due to its critical nature.

2. When assessing a client with pneumonia, which clinical manifestation should the nurse expect to find?

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

Correct answer: C

Rationale: In pneumonia, lung tissue consolidation occurs, leading to dullness on percussion. This is a typical finding in pneumonia. Fremitus and decreased tactile fremitus are more commonly associated with conditions like pleural effusion or pneumothorax. Hyperresonance is typically seen in conditions causing air trapping, such as emphysema.

3. A client is postoperative with shallow respirations at 9/min. Which acid-base imbalance should the nurse identify the client as being at risk for developing initially?

• A. Respiratory acidosis
• B. Respiratory alkalosis
• C. Metabolic acidosis
• D. Metabolic alkalosis

Correct answer: A

Rationale: The client's shallow respirations at 9/min indicate hypoventilation, leading to an accumulation of carbon dioxide in the blood, causing respiratory acidosis. In this scenario, the client is at risk for developing respiratory acidosis due to inadequate ventilation and subsequent CO2 retention.

4. After an open lung biopsy, a nurse assesses a client. Which assessment finding is matched with the correct intervention?

• A. Client states he is dizzy. Nurse applies oxygen and pulse oximetry.
• B. Client's HR is 55 beats/min. Nurse withholds pain medication.
• C. Client has reduced breath sounds. Nurse calls the physician immediately.
• D. Client's RR is 18 breaths/min. Nurse decreases the oxygen flow rate.

Correct answer: C

Rationale: After an open lung biopsy, a potential complication is pneumothorax, often indicated by reduced or absent breath sounds. The nurse should promptly notify the physician to address this serious issue and ensure timely intervention.

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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