Nursing Elites

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

• A. Oxygen saturation of 90%
• B. Respiratory rate of 24 breaths per minute
• C. Use of accessory muscles
• D. Inspiratory crackles

Correct answer: C

Rationale: The correct answer is C: Use of accessory muscles. In a client with COPD receiving supplemental oxygen, the use of accessory muscles is a critical finding that requires immediate intervention. This observation indicates increased work of breathing, suggesting respiratory distress. Addressing this issue promptly is crucial to prevent further respiratory compromise. Choice A, oxygen saturation of 90%, is slightly below the normal range but may not require immediate intervention unless it continues to decrease. Choice B, a respiratory rate of 24 breaths per minute, is within normal limits for an adult and does not indicate an urgent issue. Choice D, inspiratory crackles, may be present in COPD due to secretions or inflammation but do not necessitate immediate intervention unless associated with other concerning signs.

2. A woman who takes pyridostigmine for myasthenia gravis (MG) arrives at the emergency department complaining of extreme muscle weakness. Her adult daughter tells the nurse that since yesterday her mother has been unable to smile. Which assessment finding warrants immediate intervention by the nurse?

• A. Uncontrollable drooling.
• B. Inability to raise voice.
• C. Tingling of extremities.
• D. Eyelid drooping.

Correct answer: A

Rationale: Uncontrollable drooling can be a sign of a myasthenic crisis, which requires immediate medical intervention to prevent respiratory failure. Drooling indicates difficulty in swallowing, which can lead to aspiration and respiratory compromise. Inability to raise voice (choice B) and tingling of extremities (choice C) are not typically associated with myasthenic crisis. Although eyelid drooping (choice D) is a common symptom of myasthenia gravis, it is not as urgent as uncontrollable drooling in indicating a potential crisis.

3. A 12-year-old boy has a body mass index (BMI) of 28, a systolic pressure, and a glycosylated hemoglobin (HBA1C) of 7.8%. Which selection indicates that his mother understands the management of his diet?

• A. One whole-wheat bagel with cream cheese, two strips of bacon, six ounces of orange juice.
• B. Two eggs with toast and butter, 8 ounces of milk.
• C. Fresh fruit salad with low-fat yogurt.
• D. Pancakes with syrup and sausage links.

Correct answer: C

Rationale: The correct answer is C. Fresh fruit salad with low-fat yogurt is a healthier choice for managing the diet of a 12-year-old boy with a high BMI and elevated HBA1C. This choice provides a good balance of nutrients, fiber, and low-fat content, helping to lower BMI and maintain healthy blood sugar levels. Choices A, B, and D are less ideal as they contain higher levels of refined carbohydrates, saturated fats, and sugars, which can contribute to weight gain and worsen blood sugar control in this scenario.

4. A client with pneumonia has arterial blood gases levels at: pH 7.33; PaCO2 49 mm/Hg; HCO3 25 mEq/L; PaO2 95. What intervention should the nurse implement based on these results?

• A. Institute coughing and deep breathing protocols.
• B. Administer oxygen via nasal cannula.
• C. Prepare for intubation and mechanical ventilation.
• D. Increase IV fluids to improve hydration.

Correct answer: A

Rationale: The ABG results indicate respiratory acidosis due to an elevated PaCO2 (49 mm/Hg), indicating hypoventilation. The appropriate intervention for respiratory acidosis is to improve ventilation. Coughing and deep breathing protocols can help the client to effectively ventilate and improve gas exchange. Administering oxygen via nasal cannula (Choice B) may be necessary in respiratory distress situations, but addressing the underlying cause of hypoventilation is crucial. Intubation and mechanical ventilation (Choice C) are not the first-line interventions for uncomplicated respiratory acidosis. Increasing IV fluids (Choice D) does not directly address the respiratory acidosis present in this scenario.

5. When a male Korean-American client looks away when asked by the nurse to describe his problem, what is the best initial nursing action?

• A. Ask for assistance from social services to find a Korean interpreter.
• B. Establish indirect eye contact with the client.
• C. Allow several minutes for the client to respond.
• D. Repeat the question using simpler language.

Correct answer: C

Rationale: In this scenario, the best initial nursing action is to allow several minutes for the client to respond. This approach respects the cultural norms of the client, as in some cultures, direct eye contact may be perceived as disrespectful or intrusive. By giving the client time to gather his thoughts and respond at his own pace, the nurse promotes effective communication and demonstrates cultural sensitivity. Asking for assistance from social services to find a Korean interpreter (Choice A) may be necessary for further communication but is not the best initial action. Establishing indirect eye contact (Choice B) may still make the client uncomfortable. Repeating the question using simpler language (Choice D) may not address the underlying cultural aspect affecting the client's response.

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