Nursing Elites

1. A young adult male is admitted to the intensive care unit with multiple rib fractures and severe pulmonary contusions after falling 20 feet from a rooftop. The Chest X-ray suggests acute Respiratory distress Syndrome. Which assessment finding warrants immediate intervention by the Nurse?

• A. Apical pulse 58 bpm.
• B. Core body temperature 100.8°F.
• C. Tachypnea with dyspnea.
• D. Multiple bruises over the chest area.

Correct answer: C

Rationale: In a patient with multiple rib fractures, severe pulmonary contusions, and possible acute Respiratory Distress Syndrome (ARDS), tachypnea (rapid breathing) with dyspnea (shortness of breath) is a critical sign of respiratory distress that warrants immediate intervention by the nurse. Tachypnea and dyspnea indicate inadequate oxygenation and ventilation, which can lead to respiratory failure if not addressed promptly. The other options, such as apical pulse rate, core body temperature, and bruises over the chest area, are important assessments but do not directly indicate the immediate need for intervention in a patient with respiratory distress.

2. A client with chronic heart failure is experiencing dyspnea and has an oxygen saturation of 88%. Which position is most appropriate to improve oxygenation?

• A. Supine with legs elevated
• B. High Fowler's position
• C. Prone with pillows under the chest
• D. Side-lying with head flat

Correct answer: B

Rationale: The correct answer is B: High Fowler's position. High Fowler's position is the most appropriate for a client with chronic heart failure experiencing dyspnea and low oxygen saturation. This position helps improve lung expansion and oxygenation by maximizing chest expansion and allowing better ventilation. Choice A, supine with legs elevated, may worsen dyspnea by reducing lung expansion. Choice C, prone with pillows under the chest, is not suitable for a client experiencing dyspnea as it may further compromise breathing. Choice D, side-lying with head flat, does not facilitate optimal lung expansion and is not the best choice for improving oxygenation in this scenario.

3. What are the clinical manifestations of otitis media?

• A. Earache, wheezing, vomiting
• B. Coughing, rhinorrhea, headache
• C. Fever, irritability, pulling on ear
• D. Wheezing, cough, drainage in ear canal

Correct answer: C

Rationale: The correct answer is C: Fever, irritability, pulling on the ear. Clinical manifestations of otitis media commonly include fever, irritability, and children may show signs of pulling or rubbing their ears. Choices A, B, and D are incorrect. Choice A includes wheezing and vomiting, which are not typical symptoms of otitis media. Choice B includes coughing, rhinorrhea, and headache, which are more commonly associated with upper respiratory infections rather than otitis media. Choice D includes wheezing, cough, and drainage in the ear canal, which are not typical clinical manifestations of otitis media.

4. The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendations should the nurse encourage the client to follow?

• A. Increase intake of high-fiber foods, such as bran cereal
• B. Restrict protein intake by limiting meats and other high-protein foods.
• C. Limit oral fluid intake to 500ml per day
• D. Increase intake of potassium-rich foods such as bananas and cantaloupe.

Correct answer: B

Rationale: The correct answer is B: Restrict protein intake by limiting meats and other high-protein foods. In glomerulonephritis, reducing protein intake helps to lower the workload on the kidneys, as excessive protein can lead to increased production of waste products that the kidneys must filter. This restriction can help prevent further damage to the kidneys. Choices A, C, and D are incorrect because: A) Increasing high-fiber foods like bran cereal is beneficial for other conditions but not specific to glomerulonephritis. C) Limiting oral fluid intake to 500ml per day is not appropriate as fluid restrictions are usually individualized based on the client's condition and kidney function. D) Increasing potassium-rich foods like bananas and cantaloupe may not be suitable for all clients with glomerulonephritis, as potassium levels can be affected in kidney disease and individual needs may vary.

5. When planning care for a client newly diagnosed with open-angle glaucoma, the nurse identifies a priority nursing problem of visual sensory/perceptual alterations. This problem is based on which etiology?

• A. Limited eye movement.
• B. Decreased peripheral vision.
• C. Blurred distance vision.
• D. Photosensitivity.

Correct answer: B

Rationale: The correct answer is B: Decreased peripheral vision. In open-angle glaucoma, decreased peripheral vision is a characteristic symptom resulting from increased intraocular pressure. This visual impairment can lead to sensory/perceptual alterations. Choice A, limited eye movement, is not directly associated with the pathophysiology of open-angle glaucoma. Choice C, blurred distance vision, is more commonly seen in conditions like myopia or presbyopia. Choice D, photosensitivity, is not a typical manifestation of open-angle glaucoma and is more commonly associated with conditions like migraines or certain medications.

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