Nursing Elites

1. The nurse is assessing a client with pneumonia who is receiving oxygen therapy. Which finding indicates that the therapy is effective?

• A. The client's respiratory rate is 20 breaths per minute.
• B. The client's arterial blood gases show a pH of 7.35.
• C. The client's oxygen saturation is 92%.
• D. The client's breath sounds are clear.

Correct answer: A

Rationale: A respiratory rate of 20 breaths per minute indicates effective oxygen therapy. In pneumonia, the respiratory rate typically increases due to the body's effort to improve oxygenation. Option B (pH of 7.35) is related to acid-base balance, not specifically indicating oxygen therapy effectiveness. Option C (oxygen saturation of 92%) is below the normal range (95-100%), suggesting the need for oxygen therapy. Option D (clear breath sounds) is a positive finding but not a direct indicator of oxygen therapy effectiveness.

2. A nurse has started a group for senior citizens in a church setting. The group decides that their first project will be to begin a program for home-bound members. Which program outcome is the best measure of the project's effectiveness?

• A. number of home-bound seniors who are visited
• B. number of church members who are over 65
• C. average annual income for the homebound members
• D. calls received showing interest in the program

Correct answer: A

Rationale: The number of home-bound seniors visited is the best measure of the project's effectiveness as it directly reflects the reach and impact of the program. Choice B is incorrect as it does not directly relate to the effectiveness of the program for home-bound seniors. Choice C is irrelevant as the average annual income of home-bound members is not a direct measure of the program's effectiveness. Choice D, calls showing interest, is not as direct a measure as the actual visits to the home-bound seniors.

3. During a health assessment for a family with a history of cardiovascular disease, which family member should be prioritized for further evaluation and intervention?

• A. a 45-year-old father who smokes and has high cholesterol
• B. a 17-year-old daughter who is overweight and inactive
• C. a 50-year-old mother with a history of hypertension
• D. a 12-year-old son who has a normal weight and is active

Correct answer: A

Rationale: The 45-year-old father who smokes and has high cholesterol should be prioritized for further evaluation and intervention. He has multiple risk factors for cardiovascular disease, including smoking and high cholesterol, which significantly increase his risk. Addressing these modifiable risk factors is crucial in preventing cardiovascular events. The daughter (Choice B) and mother (Choice C) also have risk factors, but the father's combination of smoking and high cholesterol places him at higher immediate risk, demanding priority intervention. The 12-year-old son (Choice D) with a normal weight and an active lifestyle has a lower risk profile and does not require immediate intervention compared to the father.

4. A client is suspected of being poisoned and presents with symmetric, descending flaccid paralysis, blurred vision, double vision, and dry mouth. The nurse should consider these findings consistent with which potential bioterrorism agent?

• A. ricin
• B. botulism toxin
• C. sulfur mustard
• D. yersinia pestis

Correct answer: B

Rationale: The correct answer is B: botulism toxin. The symptoms described, including symmetric, descending flaccid paralysis, blurred vision, double vision, and dry mouth, are classic manifestations of botulism, which is caused by a toxin produced by Clostridium botulinum. This toxin affects the nervous system, leading to muscle weakness and paralysis. Choice A, ricin, typically presents with gastrointestinal symptoms and organ failure. Choice C, sulfur mustard, causes blistering skin and respiratory issues. Choice D, yersinia pestis, is associated with the plague and presents with fever, chills, weakness, and swollen lymph nodes.

5. A client with a history of epilepsy is admitted with status epilepticus. Which medication should the nurse prepare to administer?

• A. Acetaminophen (Tylenol)
• B. Lorazepam (Ativan)
• C. Phenytoin (Dilantin)
• D. Carbamazepine (Tegretol)

Correct answer: B

Rationale: In the management of status epilepticus, the initial medication of choice is a benzodiazepine such as lorazepam (Ativan) to rapidly terminate the seizure activity. Lorazepam acts quickly and effectively in stopping seizures. Phenytoin (Dilantin) is often used as a second-line agent for status epilepticus, and carbamazepine (Tegretol) is not typically indicated for the acute treatment of status epilepticus. Acetaminophen (Tylenol) is a pain reliever and antipyretic but is not used in the treatment of status epilepticus.

Similar Questions