Nursing Elites

1. 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.

2. A client has a pulmonary embolism & is started on oxygen. The student nurse asks why the client's oxygen saturation has not significantly improved. What response by the nurse is best?

• A. Breathing so rapidly interferes with oxygenation.
• B. Maybe the client has respiratory distress syndrome.
• C. The blood clot interferes with perfusion in the lungs.
• D. The client needs immediate intubation & mechanical ventilation.

Correct answer: C

Rationale: A large blood clot in the lungs will significantly impair gas exchange & oxygenation. Unless the clot is dissolved, this process will continue unabated.

3. A healthcare provider suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which of the following should be the healthcare provider's priority intervention?

• A. Insert an IV line
• B. Count the respiratory rate
• C. Administer oxygen
• D. Prepare equipment for intubation

Correct answer: B

Rationale: When suspecting anaphylaxis, the priority intervention is to assess the client's respiratory status by counting the respiratory rate. Respiratory distress is a hallmark sign of anaphylaxis, and prompt recognition and management are crucial. Administering oxygen may be necessary, but assessing the respiratory rate takes precedence to determine the severity of the reaction and the need for immediate intervention. Inserting an IV line and preparing for intubation are important interventions in managing anaphylaxis but are secondary to ensuring adequate ventilation.

4. A client's arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mm Hg. The client is experiencing which of the following acid-base imbalances?

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

Correct answer: C

Rationale: In respiratory acidosis, there is an excess of carbon dioxide (PaCO2 > 45 mm Hg) leading to a decrease in pH (<7.35). The given values of a pH of 7.3 and PaCO2 of 50 mm Hg indicate respiratory acidosis. Metabolic acidosis involves a primary decrease in bicarbonate levels with a compensatory decrease in PaCO2 to maintain balance. Metabolic alkalosis is characterized by elevated pH and bicarbonate levels. Respiratory alkalosis is marked by low PaCO2 and increased pH levels.

5. When teaching a group of clients about emergency care for a snake bite, which of the following information should the nurse include?

• A. Raise the affected extremity above the level of the heart.
• B. Immobilize the affected extremity with a splint
• C. Apply ice to the bite area
• D. Apply a tourniquet to the affected extremity.

Correct answer: B

Rationale: In cases of snake bites, it is essential to immobilize the affected extremity with a splint to prevent the spread of venom throughout the body. Raising the extremity above the heart level can promote venom spread, and applying ice or a tourniquet can worsen the condition. Immobilization helps reduce movement and slows the circulation of venom, aiding in the prevention of further complications.

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