Nursing Elites

1. A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this include? (SATA)

• A. Age
• B. Hypertension
• C. Obesity
• D. Smoking

Correct answer: B

Rationale: Hypertension, obesity, smoking, and excessive stress are all modifiable risk factors for coronary artery disease. Age is a nonmodifiable risk factor as it is a natural process of life.

2. A client with chronic obstructive pulmonary disease (COPD) receives oxygen therapy. Which finding requires immediate intervention by the nurse?

• A. Oxygen saturation of 91%
• B. Respiratory rate of 10 breaths per minute
• C. Client reports shortness of breath
• D. Use of accessory muscles

Correct answer: B

Rationale: A respiratory rate of 10 breaths per minute in a client with COPD receiving oxygen therapy may indicate respiratory depression, necessitating immediate intervention. An oxygen saturation of 91%, client reports of shortness of breath, and use of accessory muscles are expected in COPD clients.

3. Prior to a thoracentesis, what intervention should the nurse complete?

• A. Measure oxygen saturation before and after the procedure.
• B. Verify that the client has given informed consent.
• C. Explain the procedure briefly to the client and their family.
• D. Ensure informed consent has been obtained from the client.

Correct answer: D

Rationale: Before a thoracentesis procedure, it is crucial to ensure that the client has given informed consent. This process involves explaining the procedure, its risks, benefits, and alternatives to the client, and obtaining their signature on the consent form. Verifying informed consent is a vital legal and ethical step to protect the client's autonomy and ensure they have made an informed decision about the procedure.

4. A client is caring for a postoperative client on the surgical unit. The client's blood pressure was 142/76 mm Hg 30 minutes ago and is now 88/50 mm Hg. What action by the nurse is best?

• A. Call the Rapid Response Team.
• B. Document and continue to monitor.
• C. Notify the primary care provider.
• D. Repeat blood pressure measurement in 15 minutes.

Correct answer: A

Rationale: In this scenario, the significant drop in blood pressure indicates a potential emergency situation. The correct action is to call the Rapid Response Team (RRT) to ensure prompt intervention and prevent further deterioration that could lead to respiratory or cardiac arrest. It is crucial to act swiftly in response to such a critical change in vital signs to provide the client with the necessary care and support.

5. A client has developed atelectasis postoperatively. Which of the following findings should the nurse expect?

• A. Facial flushing
• B. Increasing dyspnea
• C. Decreasing respiratory rate
• D. Friction rub

Correct answer: Increasing dyspnea

Rationale: Atelectasis is a condition where the alveoli in the lungs collapse, leading to impaired gas exchange. As a result, the client may experience increasing dyspnea (difficulty breathing) due to the decreased lung capacity for oxygen exchange. Facial flushing, decreasing respiratory rate, and friction rub are not typically associated with atelectasis.

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