Nursing Elites

1. After auscultating a client's breath sounds, the nurse is providing care. Which finding is correctly matched to the nurse's primary intervention?

• A. Hollow sounds are heard over the trachea. The nurse increases the oxygen flow rate.
• B. Crackles are heard in bases. The nurse encourages the client to cough forcefully.
• C. Wheezes are heard in central areas. The nurse administers an inhaled bronchodilator.
• D. Vesicular sounds are heard over the periphery. The nurse has the client breathe deeply.

Correct answer: C

Rationale: Wheezes are indicative of narrowed airways, and bronchodilators help to open the air passages, making option C the correct match. Wheezes are typically heard in the central or peripheral lung areas and are associated with conditions like asthma or COPD. Inhaled bronchodilators work by dilating the bronchioles, which helps alleviate wheezing and improve airflow. Therefore, administering an inhaled bronchodilator is the appropriate intervention in response to wheezes.

2. A client is 12 hours postoperative following colon resection. Which of the following interventions should the nurse include in the plan to reduce respiratory complications?

• A. Use incentive spirometer every 4 hours while awake.
• B. Initiate ambulation after discontinuing the NG tube.
• C. Maintain a supine position with an abdominal binder.
• D. Splint the incision to support coughing every 2 hours.

Correct answer: D

Rationale: Following a colon resection surgery, it is essential to support the incision site to reduce the risk of respiratory complications. Splinting the incision helps to minimize pain during coughing, aiding in effective clearing of secretions and preventing respiratory problems. This intervention supports the client's respiratory function postoperatively, promoting optimal recovery.

3. A client is receiving oxygen therapy via nasal cannula. Which finding indicates that the therapy is effective?

• A. The client is able to ambulate in the hall without dyspnea.
• B. The client has a respiratory rate of 24 breaths per minute.
• C. The client's oxygen saturation is 92%.
• D. The client has a productive cough.

Correct answer: A

Rationale: The correct answer is A. Effective oxygen therapy should improve the client's ability to perform activities without dyspnea. This indicates that the oxygen therapy is adequately supporting the client's respiratory needs. An oxygen saturation of 92% may suggest the need for a higher flow rate to improve oxygenation. A respiratory rate of 24 breaths per minute is elevated, indicating potential respiratory distress. A productive cough does not necessarily indicate effective oxygen therapy, as it is a symptom of respiratory irritation or infection, not oxygenation status.

4. A client with acute respiratory failure (ARF) is being cared for by a nurse. The nurse should monitor the client for which of the following manifestations of this condition?

• A. Severe dyspnea
• B. Nausea
• C. Decreased level of consciousness
• D. Headache

Correct answer: B

Rationale: In acute respiratory failure, the body is not getting enough oxygen, leading to hypoxia. Symptoms of hypoxia include severe dyspnea (A), decreased level of consciousness (C), and headache (D) due to inadequate oxygen supply to the brain. Nausea (B) is not a typical manifestation of acute respiratory failure and is not directly related to the lack of oxygen in the body. Therefore, the nurse should not monitor the client for nausea as a direct consequence of ARF.

5. A nurse is caring for a client post-myocardial infarction (MI). What is the priority assessment for this client?

• A. Monitoring urine output
• B. Checking blood glucose levels
• C. Assessing for chest pain
• D. Monitoring electrolyte levels

Correct answer: C

Rationale: Assessing for chest pain is crucial in post-MI clients as it can indicate complications such as reinfarction or ischemia.

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