Nursing Elites

1. A nurse is preparing to perform a focused respiratory assessment on a client with COPD. What is an expected finding?

• A. Normal respiratory rate
• B. Nasal flaring
• C. Decreased breath sounds
• D. Increased breath sounds

Correct answer: B

Rationale: Nasal flaring is an expected finding in clients with COPD who are experiencing respiratory distress. Nasal flaring is a sign of increased work of breathing and respiratory distress, commonly seen in clients with COPD exacerbation. Choices A, C, and D are incorrect. A normal respiratory rate would not be an expected finding in a client with COPD, as they often have an increased respiratory rate. Decreased breath sounds could indicate diminished airflow but are not typically a common finding in COPD. Increased breath sounds are not typical in COPD and could indicate other conditions like pneumonia.

2. A healthcare provider is assessing the pain level of a client who has dementia and difficulty communicating. Which pain assessment technique should the healthcare provider use?

• A. Verbal self-report
• B. Pain scale
• C. Behavioral indicators
• D. Observing facial expressions

Correct answer: C

Rationale: In clients with dementia and difficulty communicating, using behavioral indicators such as agitation and restlessness is more reliable for assessing pain than relying on verbal self-report, pain scales, or observing facial expressions. Verbal self-report may not be possible due to communication challenges, pain scales may be difficult for the client to comprehend, and observing facial expressions alone may not provide a comprehensive assessment of pain in individuals with dementia.

3. A nurse is caring for a client who is experiencing fluid volume deficit (FVD). What clinical finding should the nurse expect?

• A. Decreased hematocrit
• B. Increased heart rate
• C. Increased blood pressure
• D. Decreased respiratory rate

Correct answer: B

Rationale: Increased heart rate is a common sign of fluid volume deficit (FVD) as the body compensates for decreased fluid levels. When a client is experiencing FVD, the body tries to maintain perfusion to vital organs by increasing the heart rate. This compensatory mechanism helps to improve cardiac output and maintain blood pressure. Choices A, C, and D are incorrect because in FVD, hematocrit may be increased due to hemoconcentration, blood pressure tends to decrease as a compensatory response to FVD, and respiratory rate is usually unaffected or may increase due to attempts to maintain oxygenation.

4. A client with an indwelling urinary catheter is being cared for by a nurse. What finding indicates a catheter occlusion?

• A. Bladder distention
• B. Frequent urination
• C. Hematuria
• D. Burning sensation

Correct answer: A

Rationale: Bladder distention is the correct answer as it indicates that the catheter is not draining properly, which is a sign of occlusion. Frequent urination, hematuria, and burning sensation are not indicative of a catheter occlusion. Frequent urination may suggest a bladder that is not fully emptying, hematuria indicates blood in the urine, and a burning sensation can be a sign of a urinary tract infection, none of which directly relate to a catheter occlusion.

5. A nurse is completing an admission assessment for a client who has hearing loss. What action should the nurse take?

• A. Use written communication
• B. Speak louder than usual
• C. Face the client when speaking
• D. Provide care in a quiet environment

Correct answer: A

Rationale: Using written communication is the most effective action for a nurse when assessing a client with hearing loss. This method helps overcome communication barriers by providing information visually, ensuring the client understands the assessment questions and instructions. Speaking louder (choice B) may distort the sound and not necessarily improve understanding. Facing the client (choice C) is important for lip reading but may not be sufficient for effective communication. Providing care in a quiet environment (choice D) is beneficial but might not fully address the need for clear communication in the assessment process for a client with hearing loss.

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