Nursing Elites

1. A nursing student asks what essential hypertension is. What response by the registered nurse is best?

• A. It means it is caused by another disease.
• B. It means it is essential that it be treated.
• C. It is hypertension with no specific cause.
• D. It refers to severe and life-threatening hypertension.

Correct answer: C

Rationale: Essential hypertension, also known as primary or idiopathic hypertension, is the most common type of hypertension. It has no specific underlying cause such as an associated disease process. In contrast, hypertension that is due to another disease is referred to as secondary hypertension. Malignant hypertension is a severe and life-threatening form of hypertension characterized by rapidly progressive blood pressure elevation and potential end-organ damage.

2. 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.

3. A client with chronic obstructive pulmonary disease (COPD) who has been receiving oxygen therapy at 2 L/min now has a respiratory rate of 10 breaths/min. What action should the nurse take first?

• A. Increase the oxygen flow rate to 4 L/min.
• B. Administer a bronchodilator via nebulizer.
• C. Encourage the client to take deep breaths.
• D. Assess the client's mental status and level of consciousness.

Correct answer: D

Rationale: The priority action for the nurse is to assess the client's mental status and level of consciousness. This assessment helps determine if the decreased respiratory rate is affecting the client's oxygenation. By evaluating the client's mental status and level of consciousness, the nurse can promptly identify any signs of respiratory distress or hypoxia, allowing for timely intervention and appropriate adjustments to the oxygen therapy or other treatments.

4. During an assessment of the respiratory pattern of an older adult client receiving end-of-life care, which of the following assessment findings should the nurse identify as Cheyne-Stokes respirations?

• A. Breathing ranging from very deep to very shallow with periods of apnea
• B. Shallow to normal breaths alternating with periods of apnea
• C. Rapid respirations that are unusually deep and regular
• D. An inability to breathe without dyspnea unless sitting upright

Correct answer: A

Rationale: Cheyne-Stokes respirations are characterized by a pattern of breathing that ranges from very deep to very shallow with periods of apnea (temporary cessation of breathing). This pattern is often seen in clients near the end of life or with certain medical conditions affecting the respiratory control center in the brain. The alternating deep and shallow breaths can be distressing for both the client and caregivers. It is crucial for the nurse to recognize this pattern to provide appropriate care and support to the client and their family during this challenging time.

5. A client with chronic obstructive pulmonary disease (COPD) is being assessed by a nurse. Which finding should the nurse expect?

• A. Increased anterior-posterior (AP) chest diameter
• B. Decreased respiratory rate
• C. Weight gain
• D. Productive cough with yellow sputum

Correct answer: A

Rationale: In COPD, the client often develops a barrel chest, characterized by an increased anterior-posterior diameter of the chest. This change is due to air trapping and hyperinflation of the lungs. Decreased respiratory rate, weight gain, and productive cough with yellow sputum are not typically associated with COPD. Weight loss is more common due to increased work of breathing and decreased energy expenditure in individuals with COPD.

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