Nursing Elites

1. A client presents with shortness of breath, pain in the lung area, and a recent history of starting birth control pills and smoking. Vital signs include a heart rate of 110/min, respiratory rate of 40/min, and blood pressure of 140/80 mm Hg. Arterial blood gases reveal pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. What is the priority nursing intervention?

• A. Prepare for mechanical ventilation.
• B. Administer oxygen via face mask.
• C. Prepare to administer a sedative.
• D. Assess for indications of pulmonary embolism.

Correct answer: B

Rationale: In a client with a high respiratory rate, low PaO2, and low SaO2, the priority intervention is to improve oxygenation. Administering oxygen via a face mask will help increase the oxygen supply to the client's lungs and tissues, addressing the hypoxemia. While mechanical ventilation may be necessary in severe cases, administering oxygen is the initial and most appropriate intervention to address the client's respiratory distress. Sedatives should not be given without ensuring adequate oxygenation. Assessing for pulmonary embolism is important but not the priority at this moment when the client is experiencing respiratory distress and hypoxemia.

2. A nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates the client is managing this condition well with diet?

• A. A 4-ounce steak, French fries, iceberg lettuce
• B. Baked chicken breast, broccoli, tomatoes
• C. Fried catfish, cornbread, peas
• D. Spaghetti with meat sauce, garlic bread

Correct answer: B

Rationale: The diet recommended for this client would be low in saturated fats & red meat, high in vegetables & whole grains (fiber), low in salt, & low in trans-fat. The best choice is the chicken with broccoli & tomatoes. The French fries have too much fat & the iceberg lettuce has little fiber. The catfish is fried. The spaghetti dinner has too much red meat & no vegetables.

3. A nursing student asks what essential hypertension is. What response by the registered nurse is best?

• A. It means it is caused by another disease.
• B. It means it is essential that it be treated.
• C. It is hypertension with no specific cause.
• D. It refers to severe and life-threatening hypertension.

Correct answer: C

Rationale: Essential hypertension, also known as primary or idiopathic hypertension, is the most common type of hypertension. It has no specific underlying cause such as an associated disease process. In contrast, hypertension that is due to another disease is referred to as secondary hypertension. Malignant hypertension is a severe and life-threatening form of hypertension characterized by rapidly progressive blood pressure elevation and potential end-organ damage.

4. A client is being treated for inhalational anthrax following bioterrorism exposure. Which of the following medications should NOT be expected as a common treatment for anthrax?

• A. Ciprofloxacin
• B. Doxycycline
• C. Amoxicillin
• D. Penicillin G

Correct answer: D

Rationale: Penicillin G is NOT commonly used to treat anthrax. Anthrax is typically treated with antibiotics such as ciprofloxacin and doxycycline due to penicillin's limited efficacy against anthrax bacteria. Amoxicillin is also not a preferred choice for anthrax treatment. Therefore, penicillin G would not be expected as a primary medication for anthrax treatment following bioterrorism exposure.

5. A client has returned from the surgical suite following surgery for a fractured mandible with intermaxillary fixation. Which of the following actions is the priority for the nurse to take?

• A. Prevent aspiration.
• B. Ensure adequate nutrition.
• C. Promote oral hygiene.
• D. Relieve the client's pain.

Correct answer: A

Rationale: Preventing aspiration is the priority for a client with intermaxillary fixation following mandibular surgery. Aspiration can occur due to difficulty swallowing or improper positioning, posing a serious risk to the client's respiratory status. It is crucial for the nurse to ensure that the client's airway is clear and that they are positioned correctly to prevent any potential aspiration events.

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