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. The trauma unit nurse has received a report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?

• A. Evaluate chest expansion.
• B. Check pupillary response to light.
• C. Assess the capillary refill.
• D. Check the client's response to questions about place and time.

Correct answer: A

Rationale: In a client with multiple injuries following a motor vehicle crash, the priority is to assess for any compromised airway or breathing. Evaluating chest expansion helps the nurse determine if the client is having any difficulty breathing, which is essential for immediate intervention to maintain adequate oxygenation. Checking pupillary response, assessing capillary refill, and checking the client's orientation to place and time are important assessments but are of lower priority compared to ensuring the client's airway and breathing are intact.

3. A healthcare professional is auscultating the lungs of a client who has pleurisy. Which of the following adventitious breath sounds should the professional expect to hear?

• A. Loud, scratchy sounds
• B. Squeaky, musical sounds
• C. Popping sounds
• D. Snoring sounds

Correct answer: A

Rationale: When auscultating the lungs of a client with pleurisy, the healthcare professional should expect to hear loud, scratchy sounds. These sounds are characteristic of pleurisy, which is an inflammation of the pleura, causing a rough, grating sound during breathing.

4. A client with end-stage renal disease (ESRD) is receiving hemodialysis. Which assessment finding indicates a need for immediate action?

• A. Weight gain of 1 kg since the last dialysis session
• B. Blood pressure of 150/90 mm Hg
• C. Potassium level of 6.5 mEq/L
• D. Hemoglobin level of 10 g/dL

Correct answer: C

Rationale: A potassium level of 6.5 mEq/L is critically high and can lead to life-threatening cardiac dysrhythmias, requiring immediate intervention. Hyperkalemia is a common complication in clients with ESRD due to the kidneys' inability to excrete potassium effectively. High potassium levels can result in serious cardiac consequences such as arrhythmias, cardiac arrest, and death. Prompt action is necessary to prevent these severe complications.

5. A nurse in a provider's office is assessing a client. Which of the following findings is not a manifestation of pulmonary tuberculosis?

• A. Night sweats
• B. Low-grade fever
• C. Weight gain
• D. Blood in the sputum

Correct answer: C

Rationale:

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