Nursing Elites

1. During auscultation of the anterior chest wall of a client newly admitted to a medical-surgical unit, what type of breath sounds should a nurse expect to hear?

• A. Normal breath sounds
• B. Adventitious breath sounds
• C. Absent breath sounds
• D. Diminished breath sounds

Correct answer: A

Rationale: During auscultation of the chest, normal breath sounds are the expected findings in a client who is newly admitted without respiratory complaints. Normal breath sounds indicate proper airflow through the airways without any abnormalities. Adventitious breath sounds (Choice B) refer to abnormal lung sounds such as crackles or wheezes, which are indicative of underlying respiratory issues. Absent breath sounds (Choice C) suggest a lack of airflow to a particular lung area, which could be due to conditions like pneumothorax. Diminished breath sounds (Choice D) indicate reduced airflow or consolidation in a specific lung region, often seen in conditions like pleural effusion or pneumonia. Therefore, in a newly admitted client without respiratory complaints, the nurse should expect to hear normal breath sounds during auscultation.

2. A client is being treated for diabetic ketoacidosis (DKA). Which laboratory value would be most concerning?

• A. Blood glucose of 350 mg/dL
• B. Serum bicarbonate of 18 mEq/L
• C. Arterial pH of 7.20
• D. Serum potassium of 5.5 mEq/L

Correct answer: C

Rationale: In a client with diabetic ketoacidosis (DKA), the most concerning laboratory value is an arterial pH of 7.20. An arterial pH of 7.20 indicates severe acidosis, which is a critical condition requiring immediate intervention. This pH level reflects a significant imbalance in the body's acid-base status, potentially leading to serious complications. High blood glucose levels (choice A) are expected in DKA but do not directly indicate the severity of acidosis. A serum bicarbonate level of 18 mEq/L (choice B) is low but not as immediately critical as a pH of 7.20. Serum potassium of 5.5 mEq/L (choice D) is elevated, which can occur in DKA due to insulin deficiency, but it is not the most concerning value in this scenario.

3. The nurse is caring for a 4-year-old 2 hours after tonsillectomy and adenoidectomy. Which of the following assessments must be reported immediately?

• A. Vomiting of dark emesis
• B. Complaints of throat pain
• C. Apical heart rate of 110
• D. Increased restlessness

Correct answer: D

Rationale: Increased restlessness must be reported immediately as it may indicate bleeding or other complications post-tonsillectomy and adenoidectomy. This could be a sign of a developing issue that requires urgent intervention. Vomiting of dark emesis, complaints of throat pain, and an apical heart rate of 110 are important to monitor but do not indicate an immediate need for reporting as compared to the potential seriousness of increased restlessness in this scenario.

4. The healthcare provider is assessing a client with a history of congestive heart failure. Which assessment finding would be most concerning?

• A. Shortness of breath on exertion
• B. Weight gain of 2 pounds in a week
• C. Orthopnea
• D. Crackles in the lungs

Correct answer: D

Rationale: Crackles in the lungs are concerning because they indicate pulmonary congestion, a serious complication of congestive heart failure. The presence of crackles suggests fluid accumulation in the lungs, requiring immediate attention to prevent respiratory distress and worsening heart failure. While shortness of breath on exertion, weight gain, and orthopnea are common signs and symptoms of heart failure, crackles specifically point to acute pulmonary edema or worsening congestion, making them the most concerning finding in this scenario.

5. Which serum blood finding in diabetic ketoacidosis alerts the nurse that immediate action is required?

• A. pH below 7.3
• B. Potassium of 5.0
• C. HCT of 60
• D. PaO2 of 79%

Correct answer: C

Rationale: A hematocrit (HCT) of 60 indicates severe dehydration, a critical condition in diabetic ketoacidosis that requires immediate intervention. Severe dehydration can lead to hypovolemic shock and organ failure. While a low pH below 7.3 is indicative of acidosis, it may not require immediate action compared to severe dehydration. A potassium level of 5.0 is within the normal range and not a critical finding in this scenario. PaO2 of 79% reflects oxygenation status, which is important but not the most critical finding requiring immediate action in diabetic ketoacidosis.

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