Nursing Elites

1. A healthcare provider is assessing a client with chronic obstructive pulmonary disease (COPD) receiving oxygen therapy. Which of the following findings indicates oxygen toxicity?

• A. Oxygen saturation 94%
• B. Decreased respiratory rate
• C. Wheezing
• D. Peripheral cyanosis

Correct answer: B

Rationale: The correct answer is B: Decreased respiratory rate. In clients with COPD, especially when receiving oxygen therapy, a decreased respiratory rate is indicative of oxygen toxicity. This occurs because their respiratory drive is often dependent on low oxygen levels. Oxygen saturation of 94% is within an acceptable range and does not necessarily indicate oxygen toxicity. Wheezing is more commonly associated with airway narrowing or constriction, while peripheral cyanosis is a sign of decreased oxygen levels in the peripheral tissues, not oxygen toxicity.

2. A nurse is preparing to perform a routine abdominal assessment for a client. Which action should the nurse take?

• A. Perform palpation before auscultation
• B. Perform percussion before auscultation
• C. Perform palpation after auscultation
• D. Perform inspection after auscultation

Correct answer: C

Rationale: The correct answer is C: Perform palpation after auscultation. When conducting an abdominal assessment, the correct sequence is inspection, auscultation, percussion, and then palpation. Inspecting the abdomen allows the nurse to observe any visible abnormalities, followed by listening for bowel sounds during auscultation. Percussion helps assess the density of abdominal contents before palpation for tenderness, masses, or organ enlargement. Choices A, B, and D are incorrect because palpation should always come last in the sequence of an abdominal assessment.

3. A nurse is preparing to administer an enteral tube feeding through an NG tube at 250 mL over 4 hr. The nurse should set the pump to deliver how many mL/hr?

• A. 60 mL/hr
• B. 62 mL/hr
• C. 63 mL/hr
• D. 65 mL/hr

Correct answer: C

Rationale: Calculation: 250 mL / 4 hours = 62.5 mL/hr, which should be rounded up to 63 mL/hr. This ensures the correct rate is set for continuous feeding. Choice A (60 mL/hr) is incorrect as it does not reflect the accurate calculation. Choice B (62 mL/hr) is close but does not round up to the nearest whole number as required. Choice D (65 mL/hr) is higher than the correct calculation and would deliver the feeding solution at a faster rate than prescribed.

4. A nurse is caring for a client with chronic pain. Which of the following interventions should the nurse prioritize?

• A. Administer pain medications as prescribed
• B. Encourage physical activity
• C. Monitor for depression
• D. Educate about alternative therapies

Correct answer: A

Rationale: Administering pain medications as prescribed is a priority to manage chronic pain effectively. Pain medications help alleviate the client's discomfort and improve their quality of life. Encouraging physical activity, monitoring for depression, and educating about alternative therapies are important interventions but may not directly address the immediate need for pain relief in a client with chronic pain. Physical activity and alternative therapies can be beneficial as part of a holistic pain management plan, but addressing the pain directly should be the initial priority.

5. A 65-year-old client is taking methylprednisolone. What pharmacological action should the nurse expect with this therapy?

• A. Suppression of beta2 receptors.
• B. Suppression of airway mucus production.
• C. Fortification of bones.
• D. Suppression of candidiasis.

Correct answer: B

Rationale: The correct answer is B: 'Suppression of airway mucus production.' Methylprednisolone, a corticosteroid, is known to suppress airway mucus production. While corticosteroids can enhance the responsiveness of beta2 receptors, they are not directly involved in the suppression of these receptors (Choice A). Corticosteroids can lead to adverse effects such as bone loss, rather than fortification of bones (Choice C). They can also increase the risk of infections like candidiasis but do not directly suppress it (Choice D). Therefore, the most expected pharmacological action of methylprednisolone therapy is the suppression of airway mucus production.

Similar Questions