Nursing Elites

1. A client with chronic obstructive pulmonary disease (COPD) who has been receiving oxygen therapy at 2 L/min now has a respiratory rate of 10 breaths/min. What action should the nurse take first?

• A. Increase the oxygen flow rate to 4 L/min.
• B. Administer a bronchodilator via nebulizer.
• C. Encourage the client to take deep breaths.
• D. Assess the client's mental status and level of consciousness.

Correct answer: D

Rationale: The priority action for the nurse is to assess the client's mental status and level of consciousness. This assessment helps determine if the decreased respiratory rate is affecting the client's oxygenation. By evaluating the client's mental status and level of consciousness, the nurse can promptly identify any signs of respiratory distress or hypoxia, allowing for timely intervention and appropriate adjustments to the oxygen therapy or other treatments.

2. A client has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor?

• A. Confusion
• B. Weakness
• C. Increased intracranial pressure
• D. Increased urinary output

Correct answer: B

Rationale: In myasthenia gravis, a neuromuscular disorder characterized by muscle weakness and fatigue, weakness is a common manifestation due to the immune system attacking the communication between nerves and muscles. Monitoring for weakness is crucial to assess the disease progression and determine the effectiveness of treatment. Confusion is not a typical manifestation of myasthenia gravis. Increased intracranial pressure and increased urinary output are not directly associated with this condition.

3. A client with heart failure has gained 2 kg (4.4 lbs) in the past 24 hours. What action should the nurse take first?

• A. Restrict the client's fluid intake.
• B. Assess the client's respiratory status.
• C. Administer diuretics as ordered.
• D. Notify the healthcare provider.

Correct answer: B

Rationale: Assessing the client's respiratory status is the priority as it helps determine if the weight gain is due to fluid retention affecting breathing. This assessment is crucial in addressing the immediate concern of potential respiratory distress before implementing interventions like fluid restriction, diuretics, or notifying the healthcare provider.

4. A client had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?

• A. Poor impulse control
• B. Inability to discriminate words and letters
• C. Deficits in the right visual field
• D. Motor retardation

Correct answer: A

Rationale: A stroke affecting the right cerebral hemisphere can lead to poor impulse control due to the involvement of this area in regulating behavior and inhibiting impulses. Deficits in the right visual field are associated with stroke affecting the left cerebral hemisphere. Inability to discriminate words and letters may be seen in left cerebral hemisphere strokes. Motor retardation may be observed with strokes affecting motor areas in either hemisphere but is not the most specific finding related to a right cerebral hemisphere stroke.

5. A client is 1-day postoperative following a left lower lobectomy and has a chest tube in place. When assessing the client's three-chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take?

• A. Continue to monitor the client as this is an expected finding.
• B. Add more water to the suction control chamber of the drainage system.
• C. Verify that the suction regulator is on and check the tubing for leaks.
• D. Milk the chest tube and dislodge any clots in the tubing that are occluding it.

Correct answer: C

Rationale: In a three-chamber chest drainage system, the absence of bubbling in the suction control chamber indicates that no suction is being applied to the chest tube. The nurse should first verify that the suction regulator is on and check the tubing for any leaks that may be causing the lack of suction. Adding more water to the chamber or milking the chest tube are inappropriate actions and could potentially harm the client. Monitoring the client without taking action could lead to complications if the chest tube is not functioning properly.

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