Nursing Elites

1. When caring for a client with acute pancreatitis, what intervention is most appropriate?

• A. Encourage a high-protein diet.
• B. Administer pain medication as needed.
• C. Provide small, frequent meals.
• D. Increase oral fluid intake.

Correct answer: B

Rationale: Administering pain medication as needed is the most appropriate intervention for a client with acute pancreatitis. Pain management is crucial as pancreatitis can cause severe and debilitating pain. Providing pain relief is essential to improve the client's comfort and well-being.

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. What should the nurse prioritize when monitoring an older adult client immediately following a bronchoscopy?

• A. Observing for confusion
• B. Auscultating breath sounds
• C. Confirming the gag reflex
• D. Measuring blood pressure

Correct answer: C

Rationale: Following a bronchoscopy, the priority for the nurse is to confirm the gag reflex in the older adult client. This is crucial to ensure that the client's airway is protected and free from any obstruction or aspiration. Monitoring the gag reflex helps in preventing complications such as aspiration pneumonia. While auscultating breath sounds, observing for confusion, and measuring blood pressure are important assessments, confirming the gag reflex takes precedence in this situation to maintain airway patency and prevent potential respiratory complications.

4. A healthcare professional auscultates a harsh hollow sound over a client's trachea & larynx. Which action should the healthcare professional take first?

• A. Document findings.
• B. Administer O2 therapy.
• C. Position client in high-Fowler's position.
• D. Administer prescribed albuterol.

Correct answer: A

Rationale: The healthcare professional has identified bronchial breath sounds, which are normal findings over the trachea & larynx, characterized by harsh, hollow, tubular, and blowing sounds. The appropriate initial action for the healthcare professional is to document these normal findings. Oxygen therapy, administering albuterol, or repositioning the client is unnecessary as this finding does not indicate a need for intervention.

5. A nurse cares for a client with chronic obstructive pulmonary disease who has been prescribed continuous oxygen therapy at home. Which statement indicates the client correctly understands the teaching?

• A. I plan to wear my oxygen when I exercise & feel short of breath.
• B. I will use my portable oxygen when grilling burgers in the backyard.
• C. I plan to use cotton balls to cushion the oxygen tubing on my ears.
• D. I will only smoke while I am wearing my oxygen via nasal cannula.

Correct answer: C

Rationale: Cotton balls can decrease pressure ulcers from the oxygen tubing. Continuous oxygen orders mean the client should wear the oxygen at all times. Oxygen fuels a fire. Wearing oxygen while grilling & smoking increases the risk for fire.

Similar Questions