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. During an assessment in the emergency department, an older adult client with community-acquired pneumonia is found to be confused. Which of the following findings should the nurse expect?

• A. Unequal pupils
• B. Hypertension
• C. Tympany upon chest percussion
• D. Confusion

Correct answer: D

Rationale: Confusion is a common finding in older adult clients with pneumonia, often indicating hypoxia. Hypertension, unequal pupils, and tympany upon chest percussion are not typically associated with community-acquired pneumonia in older adults.

3. A client is receiving discharge teaching after a total hip replacement. Which statement by the client indicates a need for further teaching?

• A. I will avoid crossing my legs when sitting.
• B. I can sleep on my side as long as I use a pillow between my legs.
• C. I will avoid bending at the waist to pick things up.
• D. I can bend down to tie my shoes after 2 weeks.

Correct answer: D

Rationale: After a total hip replacement, clients should avoid bending at the waist past 90 degrees for at least 6 weeks to prevent dislocation of the hip prosthesis. Bending down to tie shoes involves significant hip flexion and should be avoided during the initial postoperative period to ensure proper healing and reduce the risk of complications.

4. A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse's priority?

• A. Increase the oxygen flow to 3 L/min.
• B. Assess the client's respiratory status.
• C. Call emergency services for the client.
• D. Have the client cough and expectorate secretions.

Correct answer: B

Rationale: When a client with COPD on oxygen therapy reports difficulty breathing, the priority action for the nurse is to assess the client's respiratory status. This involves evaluating the client's oxygen saturation levels, respiratory rate, effort of breathing, lung sounds, and overall respiratory distress. By assessing the client's respiratory status, the nurse can determine the severity of the situation and make appropriate decisions regarding further interventions, such as adjusting oxygen flow rate, providing respiratory treatments, or seeking emergency assistance if necessary.

5. A client has a pulmonary embolism & is started on oxygen. The student nurse asks why the client's oxygen saturation has not significantly improved. What response by the nurse is best?

• A. Breathing so rapidly interferes with oxygenation.
• B. Maybe the client has respiratory distress syndrome.
• C. The blood clot interferes with perfusion in the lungs.
• D. The client needs immediate intubation & mechanical ventilation.

Correct answer: C

Rationale: A large blood clot in the lungs will significantly impair gas exchange & oxygenation. Unless the clot is dissolved, this process will continue unabated.

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