Nursing Elites

1. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which assessment finding requires immediate intervention?

• A. Use of accessory muscles
• B. Oxygen saturation of 90%
• C. Respiratory rate of 24 breaths per minute
• D. Blood pressure of 110/70 mmHg

Correct answer: A

Rationale: The correct answer is A: Use of accessory muscles. This finding indicates increased work of breathing in a client with COPD and may signal respiratory failure, requiring immediate intervention. In COPD, the use of accessory muscles suggests that the client is in distress and struggling to breathe effectively. Oxygen saturation of 90% is within an acceptable range for a client with COPD receiving supplemental oxygen and does not require immediate intervention. A respiratory rate of 24 breaths per minute is slightly elevated but not a critical finding. A blood pressure of 110/70 mmHg is within the normal range for an adult and does not indicate a need for immediate intervention in this scenario.

2. In a client with heart failure receiving digoxin (Lanoxin) and furosemide (Lasix), which laboratory value requires immediate intervention?

• A. Serum potassium of 4.0 mEq/L
• B. Blood glucose of 200 mg/dl
• C. Serum creatinine of 1.5 mg/dl
• D. Serum potassium of 3.2 mEq/L

Correct answer: D

Rationale: A serum potassium level of 3.2 mEq/L is low and concerning in a client receiving digoxin and furosemide. Hypokalemia increases the risk of digoxin toxicity, leading to life-threatening arrhythmias. Therefore, immediate intervention is necessary to prevent complications. The other options, serum potassium of 4.0 mEq/L, blood glucose of 200 mg/dl, and serum creatinine of 1.5 mg/dl, are within normal limits and do not pose immediate risks to the client in this scenario.

3. A client with a history of severe rheumatoid arthritis is receiving a corticosteroid. Which assessment finding should the nurse report to the healthcare provider immediately?

• A. Blood glucose level of 180 mg/dL
• B. Weight gain of 2 pounds in 24 hours
• C. Blood pressure of 140/90 mmHg
• D. Increased joint pain

Correct answer: C

Rationale: Elevated blood pressure (140/90 mmHg) is a significant finding that the nurse should report immediately. Hypertension can be a severe side effect of corticosteroid therapy, especially in clients with preexisting conditions like rheumatoid arthritis. It requires prompt intervention to prevent complications such as cardiovascular events. The other options, while important to monitor, are not as critical as elevated blood pressure in this context. A blood glucose level of 180 mg/dL may indicate hyperglycemia, weight gain could be due to fluid retention, and increased joint pain is expected in a client with severe rheumatoid arthritis.

4. The nurse is assessing a 1-year-old child with bronchiolitis caused by respiratory syncytial virus (RSV). Which assessment finding requires immediate intervention?

• A. Wheezing heard on expiration
• B. Oxygen saturation of 90%
• C. Respiratory rate of 40 breaths per minute
• D. Nasal flaring with sternal retractions

Correct answer: D

Rationale: Nasal flaring with sternal retractions indicates severe respiratory distress in a 1-year-old with bronchiolitis, requiring immediate intervention. Nasal flaring and sternal retractions are signs of increased work of breathing and decreased air movement, indicating the child is struggling to breathe. Wheezing on expiration (Choice A) is common in bronchiolitis but may not require immediate intervention. An oxygen saturation of 90% (Choice B) is low but may not be the most critical finding in this case. A respiratory rate of 40 breaths per minute (Choice C) is elevated but alone may not indicate the need for immediate intervention as much as nasal flaring and sternal retractions.

5. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which finding requires immediate intervention?

• A. Oxygen saturation of 90%
• B. Respiratory rate of 24 breaths per minute
• C. Use of accessory muscles
• D. Blood pressure of 110/70 mmHg

Correct answer: C

Rationale: The correct answer is C. The use of accessory muscles indicates increased work of breathing and may signal respiratory failure in a client with COPD, requiring immediate intervention. Oxygen saturation of 90% is within an acceptable range for COPD patients on supplemental oxygen. A respiratory rate of 24 breaths per minute is slightly elevated but not an immediate concern. A blood pressure of 110/70 mmHg is within the normal range and does not require immediate intervention in this scenario.

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