Nursing Elites

1. During an asthma attack, a healthcare provider is assessing a client for hypoxemia. Which of the following manifestations should the provider expect?

• A. Nausea
• B. Dysphagia
• C. Agitation
• D. Hypotension

Correct answer: C

Rationale: During an asthma attack, hypoxemia can lead to inadequate oxygen supply to the brain, causing symptoms like restlessness, confusion, and agitation. These manifestations result from the body's response to low oxygen levels, aiming to increase oxygenation. Nausea, dysphagia, and hypotension are not typical manifestations of hypoxemia during an asthma attack.

2. 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.

3. What should the nurse prioritize when monitoring an older adult client immediately following a bronchoscopy?

• A. Observing for confusion
• B. Auscultating breath sounds
• C. Confirming the gag reflex
• D. Measuring blood pressure

Correct answer: C

Rationale: Following a bronchoscopy, the priority for the nurse is to confirm the gag reflex in the older adult client. This is crucial to ensure that the client's airway is protected and free from any obstruction or aspiration. Monitoring the gag reflex helps in preventing complications such as aspiration pneumonia. While auscultating breath sounds, observing for confusion, and measuring blood pressure are important assessments, confirming the gag reflex takes precedence in this situation to maintain airway patency and prevent potential respiratory complications.

4. A nurse is assessing a client who has COPD. The nurse should expect the client's chest to be which of the following shapes?

• A. Pigeon
• B. Funnel
• C. Kyphotic
• D. Barrel

Correct answer: D

Rationale:

5. A client with a tracheostomy experienced a coughing spell during a meal that was being fed by an unlicensed assistive personnel (UAP). What action by the nurse takes priority?

• A. Assess the client's lung sounds.
• B. Assign a different UAP to the client.
• C. Report the UAP to the manager.
• D. Request thicker liquids for meals.

Correct answer: A

Rationale: The priority action for the nurse is to assess the client's lung sounds to check for signs of aspiration, which can compromise the client's oxygenation. This is crucial to ensure the client's immediate safety and respiratory status. Once the client has been assessed, the nurse can then consider consulting with the registered dietitian regarding appropriate thickened liquids for future meals. Assigning a different UAP or reporting the UAP to the manager may be necessary steps but not the immediate priority in this situation.

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