Nursing Elites

1. A healthcare provider suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which of the following should be the healthcare provider's priority intervention?

• A. Insert an IV line
• B. Count the respiratory rate
• C. Administer oxygen
• D. Prepare equipment for intubation

Correct answer: B

Rationale: When suspecting anaphylaxis, the priority intervention is to assess the client's respiratory status by counting the respiratory rate. Respiratory distress is a hallmark sign of anaphylaxis, and prompt recognition and management are crucial. Administering oxygen may be necessary, but assessing the respiratory rate takes precedence to determine the severity of the reaction and the need for immediate intervention. Inserting an IV line and preparing for intubation are important interventions in managing anaphylaxis but are secondary to ensuring adequate ventilation.

2. While caring for a client using O2 in the hospital, what assessment finding indicates that goals for a priority diagnosis are being met?

• A. 100% of meals being eaten by the client
• B. Intact skin behind the ears
• C. The client understanding the need for oxygen
• D. Unchanged weight for the past 3 days

Correct answer: B

Rationale: When a client is using oxygen, there is a risk for impaired skin integrity due to pressure from tubing. Intact skin behind the ears suggests that the client is not experiencing skin breakdown, meeting the goals for this diagnosis. The client's nutrition, understanding of oxygen therapy, and weight stability are important but do not directly relate to the priority diagnosis of skin integrity in this context.

3. After an open lung biopsy, a nurse assesses a client. Which assessment finding is matched with the correct intervention?

• A. Client states he is dizzy. Nurse applies oxygen and pulse oximetry.
• B. Client's HR is 55 beats/min. Nurse withholds pain medication.
• C. Client has reduced breath sounds. Nurse calls the physician immediately.
• D. Client's RR is 18 breaths/min. Nurse decreases the oxygen flow rate.

Correct answer: C

Rationale: After an open lung biopsy, a potential complication is pneumothorax, often indicated by reduced or absent breath sounds. The nurse should promptly notify the physician to address this serious issue and ensure timely intervention.

4. A healthcare professional is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the healthcare professional expect?

• A. Bradycardia
• B. Bradypnea
• C. Lethargy
• D. Intercostal retractions

Correct answer: D

Rationale: Postoperative atelectasis can lead to hypoxia, which causes respiratory distress. Intercostal retractions, where the muscles between the ribs pull inward during inspiration, are a common sign of respiratory distress in a client with atelectasis. Bradycardia (slow heart rate), Bradypnea (slow breathing rate), and lethargy are not typically associated with atelectasis and hypoxia.

5. During pulmonary hygiene for a client with pneumonia, a nurse positions the client on his left side in Trendelenburg position. From which of the following lung segments should the nurse expect secretions to be mobilized with the client in this position?

• A. Lateral segment of the left lower lobe
• B. Lateral segment of the right lower lobe
• C. Posterior segment of the right middle lobe
• D. Posterior segment of the right lower lobe

Correct answer: B

Rationale: When a client is positioned on the left side in Trendelenburg position for pulmonary hygiene, secretions are expected to be mobilized from the lateral segment of the right lower lobe. This positioning helps facilitate drainage and clearance of secretions from this specific area of the lung, aiding in overall pulmonary hygiene and improving ventilation.

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