Nursing Elites

1. A healthcare professional is auscultating the lungs of a client who has pleurisy. Which of the following adventitious breath sounds should the professional expect to hear?

• A. Loud, scratchy sounds
• B. Squeaky, musical sounds
• C. Popping sounds
• D. Snoring sounds

Correct answer: A

Rationale: When auscultating the lungs of a client with pleurisy, the healthcare professional should expect to hear loud, scratchy sounds. These sounds are characteristic of pleurisy, which is an inflammation of the pleura, causing a rough, grating sound during breathing.

2. A client is prescribed prednisone for asthma management. Which statement by the client indicates a need for further teaching?

• A. I will take this medication every day to prevent asthma attacks.
• B. I will avoid people with infections while taking this medication.
• C. I will take this medication with food to prevent stomach upset.
• D. I will stop taking this medication if I feel fine.

Correct answer: D

Rationale: The correct answer is D because prednisone, a corticosteroid, should not be abruptly stopped. It must be tapered off gradually to prevent adrenal insufficiency. Choices A, B, and C demonstrate proper understanding of the medication's use and side effects, emphasizing the importance of daily intake, infection prevention, and taking it with food to avoid stomach upset.

3. A client underwent a total laryngectomy. Which of the following is the priority observation in the client's care?

• A. Patency of the intravenous line
• B. Level of pain
• C. Integrity of the dressing
• D. Need for suctioning

Correct answer: D

Rationale: Following a total laryngectomy, maintaining a clear airway is crucial to prevent complications such as airway obstruction due to secretions or blood clots. Monitoring the need for suctioning takes precedence to ensure the client's airway remains patent. While monitoring pain levels, IV line patency, and dressing integrity are important aspects of care, ensuring adequate airway clearance through suctioning is the priority in this scenario.

4. What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP) for a client receiving O2 at 4 liters per nasal cannula?

• A. Apply water-soluble ointment to nares and lips.
• B. Periodically adjust the oxygen flow rate.
• C. Remove the tubing from the client's nose.
• D. Turn the client every 2 hours or as needed.

Correct answer: A

Rationale: When a client is receiving oxygen at a high flow rate, it can cause drying of the nasal passages and lips. Therefore, a comfort measure that can be delegated to unlicensed assistive personnel (UAP) is applying water-soluble ointment to the client's nares and lips. Adjusting the oxygen flow rate should be done by licensed nursing staff, not UAP. Removing the tubing can disrupt the oxygen delivery and should be performed by trained personnel. Turning the client every 2 hours is a general comfort measure but is not specific to addressing the drying effects of oxygen therapy.

5. A client had an inferior wall myocardial infarction (MI). The nurse notes the client's cardiac rhythm as shown below. What action by the nurse is most important?

• A. Assess the client's blood pressure and level of consciousness.
• B. Call the health care provider or the Rapid Response Team.
• C. Obtain a permit for an emergency temporary pacemaker insertion.
• D. Prepare to administer antidysrhythmic medication.

Correct answer: A

Rationale: The ECG strip shows sinus bradycardia, which is common in clients with an inferior wall MI. This rhythm can lead to decreased perfusion due to bradycardia and blocks. The most crucial initial action for the nurse is to assess the client's hemodynamic status, including blood pressure and level of consciousness. This assessment will help determine the immediate needs of the client. Calling the health care provider or the Rapid Response Team, obtaining a permit for a pacemaker insertion, or preparing to administer antidysrhythmic medication may be necessary based on the assessment findings, but the priority is to evaluate the client's current condition first.

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