Nursing Elites

1. A client is postoperative, and a nurse is developing a plan of care. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications?

• A. Perform range-of-motion exercises
• B. Place suction equipment at the bedside
• C. Encourage the use of an incentive spirometer
• D. Administer an expectorant

Correct answer: C

Rationale: Encouraging the use of an incentive spirometer is vital in preventing pulmonary complications postoperatively. The incentive spirometer helps the client perform deep breathing exercises, promoting lung expansion, and preventing atelectasis. Range-of-motion exercises help prevent musculoskeletal complications, while placing suction equipment at the bedside is important but not directly related to preventing pulmonary complications. Administering an expectorant may help with clearing secretions but is not as effective in preventing postoperative pulmonary complications as using an incentive spirometer.

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 experiencing an acute exacerbation of asthma. Which medication should the nurse administer first?

• A. Albuterol (Proventil)
• B. Ipratropium (Atrovent)
• C. Salmeterol (Serevent)
• D. Fluticasone (Flovent)

Correct answer: A

Rationale: During an acute exacerbation of asthma, the priority is to administer a short-acting beta2-agonist like Albuterol (Proventil) first. Albuterol acts quickly to dilate the airways and provide immediate relief of bronchospasm. Ipratropium (Atrovent) is an anticholinergic that can be used as an adjunct therapy. Salmeterol (Serevent) is a long-acting beta2-agonist intended for maintenance therapy, not for acute exacerbations. Fluticasone (Flovent) is a corticosteroid used for long-term asthma control and should not be the initial medication given during an acute exacerbation.

4. During assessment, a healthcare provider is evaluating a client with chronic bronchitis. Which of the following percussion sounds should the healthcare provider expect?

• A. Dullness
• B. Resonance
• C. Tympany
• D. Flatness

Correct answer: B

Rationale: In a client with chronic bronchitis, the nurse or healthcare provider would expect to hear resonant sounds upon percussion. Resonance is the normal percussion sound heard over healthy lung tissue. The other options such as dullness, tympany, and flatness are associated with different conditions or abnormalities, not typically expected in chronic bronchitis.

5. 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.

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