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 assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client findings should the nurse intervene first?

• A. Urticaria
• B. Stridor
• C. Vomiting
• D. Hypotension

Correct answer: B

Rationale:

3. A client is postoperative following an intermaxillary fixation due to multiple facial fractures. Which type of equipment should be at the client's bedside?

• A. Wire cutters
• B. NG tube
• C. Urinary catheter tray
• D. IV infusion pump

Correct answer: A

Rationale: In a client who has undergone intermaxillary fixation for facial fractures, wire cutters are essential equipment to have at the bedside in case of emergencies such as airway compromise. These wire cutters allow prompt removal of the wires securing the jaw if needed to ensure adequate airway patency. NG tube, urinary catheter tray, and IV infusion pump are important pieces of equipment in various clinical scenarios but are not specifically required for managing intermaxillary fixation postoperatively.

4. A client with a pleural effusion is being assessed by a nurse. Which clinical manifestation does the nurse expect to find?

• A. Decreased breath sounds on the affected side
• B. Hyperresonance on percussion of the affected side
• C. Increased tactile fremitus on the affected side
• D. Tracheal deviation toward the affected side

Correct answer: A

Rationale: In a client with pleural effusion, decreased breath sounds on the affected side are common due to the presence of fluid in the pleural space. Hyperresonance is not expected; dullness on percussion is more likely. Tactile fremitus is typically decreased, not increased, in pleural effusion cases. Tracheal deviation away from the affected side, not toward it, can be seen with large effusions.

5. A client who will undergo a bronchoscopy procedure with a rigid scope and general anesthesia will have their neck in which of the following positions?

• A. A flexed position
• B. An extended position
• C. A neutral position
• D. A hyperextended position

Correct answer: D

Rationale: During a bronchoscopy with a rigid scope and general anesthesia, the provider will typically place the client's neck in a hyperextended position to allow better visualization and access to the airways. This position helps to align the trachea for easier insertion of the scope.

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