Nursing Elites

1. During the beginning shift assessment of a client with asthma who is receiving oxygen via nasal cannula at 2 liters per minute, the nurse would be most concerned about which unreported finding?

• A. Pulse oximetry reading of 89%
• B. Crackles at the base of the lungs on auscultation
• C. Rapid shallow respirations with intermittent wheezes
• D. Excessive thirst with a dry cracked tongue

Correct answer: C

Rationale: Rapid, shallow respirations with intermittent wheezes are concerning as they indicate a potential worsening of the client's asthma. This finding suggests airway narrowing, which can lead to respiratory failure. Immediate intervention is required to address this respiratory distress. A pulse oximetry reading of 89% is low and indicates hypoxemia, but the respiratory pattern described in option C takes priority as it directly reflects the client's respiratory status. Crackles at the base of the lungs suggest fluid accumulation, which is important but not as immediately critical as the respiratory distress in asthma. Excessive thirst and a dry cracked tongue may indicate dehydration, which is relevant but not as urgent as the respiratory compromise presented in option C.

2. Which of the following is used to monitor specific groups eligible for a particular DOH program?

• A. Family treatment record
• B. Target Client list
• C. Reporting forms
• D. Output record

Correct answer: B

Rationale: The correct answer is B: Target Client list. The Target Client list is specifically designed to monitor groups that are eligible for a particular DOH program. It helps in identifying and tracking individuals or populations that qualify for the said program. Choice A, Family treatment record, is incorrect because it pertains to the medical history and treatment information of a particular family, not eligibility monitoring. Choice C, Reporting forms, is incorrect as they are used for documenting and submitting information, not for monitoring eligibility. Choice D, Output record, is also incorrect as it refers to the results or outcomes produced by a system, not for monitoring eligibility.

3. James is an 18-month-old child who has had a cough for 7 days with no general danger signs, a temperature of 37.5°C, and a respiratory rate of 41 breaths per minute. How will you classify James' breathing?

• A. Slow breathing
• B. Fast breathing
• C. Normal breathing
• D. Very fast breathing

Correct answer: C

Rationale: The correct answer is 'Normal breathing.' A respiratory rate of 41 breaths per minute is considered normal for an 18-month-old child. Choices A, B, and D are incorrect because a respiratory rate of 41 breaths per minute falls within the normal range for a child of James' age and does not indicate slow, fast, or very fast breathing.

4. In the provision of preventive care to workers, the nurse must be aware of biological hazards that are harmful to workers and their families, such as:

• A. bacteria, fungi, and insects
• B. noise
• C. toxic metals, poisonous gas fumes, and dust
• D. stress

Correct answer: A

Rationale: The correct answer is A: bacteria, fungi, and insects. Biological hazards in the workplace can include microorganisms like bacteria and fungi that can cause infections, as well as insects that may carry diseases. Noise (choice B) is considered a physical hazard, not a biological one. Toxic metals, poisonous gas fumes, and dust (choice C) are examples of chemical hazards, not biological hazards. While stress (choice D) can be a health concern in the workplace, it is not classified as a biological hazard.

5. A client with acute pancreatitis is receiving total parenteral nutrition (TPN). The nurse should monitor the client for which of the following complications?

• A. Hypoglycemia
• B. Hyperkalemia
• C. Hyperglycemia
• D. Hyponatremia

Correct answer: C

Rationale: The correct answer is C: Hyperglycemia. Total parenteral nutrition (TPN) contains a high glucose content, which can lead to elevated blood sugar levels, resulting in hyperglycemia. Monitoring for hyperglycemia is crucial in clients receiving TPN to prevent complications such as osmotic diuresis, dehydration, and electrolyte imbalances. Choices A, B, and D are incorrect because TPN is more likely to cause hyperglycemia rather than hypoglycemia, hyperkalemia, or hyponatremia.

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