Nursing Elites

1. An older adult woman with a long history of COPD is admitted with progressive shortness of breath and a persistent cough, is anxious, and is complaining of dry mouth. Which intervention should the nurse implement?

• A. Administer a prescribed sedative
• B. Encourage client to drink water
• C. Apply a high flow venturi mask
• D. Assist her to an upright position

Correct answer: D

Rationale: Assisting the client to an upright position is the most appropriate intervention in this situation. Placing the client upright helps improve lung expansion by reducing diaphragmatic pressure, facilitating better air exchange, and increasing oxygenation. This position also aids in easing breathing efforts. Administering a sedative (Choice A) may further depress the respiratory system, worsening the breathing problem. Encouraging the client to drink water (Choice B) may not directly address the respiratory distress caused by COPD. Applying a high flow venturi mask (Choice C) may be beneficial in some cases but assisting the client to an upright position should be the priority to optimize respiratory function.

2. When conducting a class for parents about sudden infant death syndrome (SIDS), the nurse instructs the class that the infant should be placed in which position to sleep?

• A. Right side-lying
• B. Left side-lying
• C. Prone
• D. Supine

Correct answer: D

Rationale: The correct answer is D, supine. The American Academy of Pediatrics recommends placing infants on their back, or supine, to sleep as it has been shown to reduce the risk of SIDS. Choices A, B, and C are incorrect because placing infants on their right side, left side, or prone (on their stomach) respectively are not recommended sleeping positions due to the increased risk of SIDS associated with those positions.

3. A client who has a history of hyperthyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse?

• A. Facial puffiness and periorbital edema
• B. Hematocrit of 30%
• C. Cold and dry skin
• D. Further decline in LOC

Correct answer: D

Rationale: A further decline in LOC can indicate severe complications and requires immediate attention. This change may signify worsening neurological status, which could lead to life-threatening consequences if not addressed promptly. Choices A, B, and C may also be concerning in a client with a history of hyperthyroidism, but a further decline in LOC takes priority due to its potential for rapid deterioration and the need for urgent intervention.

4. Which nursing problem has the highest priority when planning care for a client with Meniere’s disease?

• A. Potential for injury related to vertigo.
• B. Alteration in comfort due to ear pain.
• C. Impaired skin integrity due to immobility.
• D. Anxiety due to fear of falling.

Correct answer: A

Rationale: The correct answer is A. When caring for a client with Meniere’s disease, the highest priority nursing problem is the potential for injury related to vertigo. Meniere’s disease is characterized by symptoms like vertigo, which can increase the risk of falls and injuries. Ensuring the client's safety and preventing falls take precedence over other concerns. Choices B, C, and D are not the highest priority because they do not directly address the immediate risk of harm associated with vertigo and falls.

5. 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.

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