Nursing Elites

1. A client is unconscious with a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?

• A. Kussmaul respirations
• B. Apneustic respirations
• C. Cheyne-Stokes respirations
• D. Stridor

Correct answer: C

Rationale: Cheyne-Stokes respirations are characterized by periods of deep, rapid breathing followed by periods of apnea. This pattern is often seen in clients with neurological or cardiac conditions. Kussmaul respirations are deep and rapid breaths often associated with metabolic acidosis. Apneustic respirations are characterized by prolonged inhalations with shortened exhalations and can indicate damage to the pons. Stridor is a high-pitched, noisy respiratory sound usually associated with upper airway obstruction. Therefore, in this scenario, the client's alternating pattern of hyperventilation and apnea aligns with Cheyne-Stokes respirations.

2. A healthcare provider is assessing a client who had a myocardial infarction. Upon auscultating heart sounds, the provider hears the following sound. What action by the provider is most appropriate?

• A. Assess the client's lung sounds.
• B. Call the Rapid Response Team.
• C. Have the client sit upright.
• D. Listen to the client's lung sounds.

Correct answer: A

Rationale: The sound described is an S3 heart sound, which can indicate heart failure. The next appropriate action for the provider is to listen to the client's lung sounds. Lung sounds can provide additional information about the client's condition, especially when abnormal heart sounds are present. Calling the Rapid Response Team is not warranted based solely on the heart sound assessment. Having the client sit upright is not directly related to addressing the abnormal heart sound.

3. A healthcare professional wishes to provide client-centered care in all interactions. Which action by the healthcare professional best demonstrates this concept?

• A. Assesses for cultural influences affecting healthcare
• B. Ensures that all the client's basic needs are met
• C. Informs the client and family about all upcoming tests
• D. Thoroughly orients the client and family to the room

Correct answer: A

Rationale: Client-centered care focuses on individualizing care to meet the client's unique needs, preferences, and values. Assessing for cultural influences affecting healthcare allows the healthcare professional to provide culturally sensitive and competent care, respecting the client's beliefs and practices. It promotes effective communication, understanding, and collaboration, essential components of client-centered care.

4. During an assessment, an older adult client's son reports that the client has been sick with a respiratory illness for the past 6 days. Which of the following assessment findings is a manifestation of pneumonia in the older adult client?

• A. Bradycardia
• B. Night sweats
• C. Confusion
• D. Narrowed pulse pressure

Correct answer: C

Rationale: Confusion is a common manifestation of pneumonia in older adults. It can result from inadequate oxygenation to the brain due to respiratory compromise. Bradycardia, night sweats, and narrowed pulse pressure are not typically specific findings associated with pneumonia and should be further assessed or monitored, but confusion is a key indicator that warrants immediate attention.

5. A client is vomiting. Which of the following actions should the nurse take first?

• A. Provide the client with an emesis basin
• B. Notify housekeeping
• C. Prevent the client from aspirating
• D. Administer an antiemetic to the client

Correct answer: C

Rationale: When a client is vomiting, the priority action for the nurse is to prevent the client from aspirating. Aspiration can lead to serious respiratory complications. Providing the client with an emesis basin can be helpful but preventing aspiration takes precedence. Notifying housekeeping and administering an antiemetic are secondary actions that can be addressed once the client's safety is ensured.

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