Nursing Elites

1. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy. Which assessment finding indicates that the client's oxygenation is improving?

• A. Pulse oximetry reading of 94%
• B. Heart rate increases from 80 to 90 beats per minute
• C. Respiratory rate increases from 16 to 20 breaths per minute
• D. Client reports increased energy levels

Correct answer: A

Rationale: A pulse oximetry reading of 94% indicates adequate oxygenation. Monitoring oxygen saturation is the most objective way to assess the effectiveness of oxygen therapy. Choices B, C, and D do not directly reflect the client's oxygenation status. An increase in heart rate or respiratory rate may indicate increased work of breathing or stress on the body. The client reporting increased energy levels is subjective and may not directly correlate with improved oxygenation.

2. A client is admitted to the hospital with a diagnosis of septic shock. Which assessment finding indicates that the client's condition is deteriorating?

• A. Heart rate of 110 beats per minute
• B. Temperature of 99.5°F (37.5°C)
• C. Blood pressure of 88/52 mmHg
• D. Respiratory rate of 24 breaths per minute

Correct answer: C

Rationale: A blood pressure of 88/52 mmHg indicates hypotension, which is a sign of worsening septic shock. Hypotension can lead to organ failure and requires immediate intervention. Elevated heart rate (choice A), mild fever (choice B), and slightly increased respiratory rate (choice D) are common in septic shock and may not necessarily indicate a deteriorating condition as much as hypotension does.

3. A client with a history of adrenal insufficiency is admitted with acute adrenal crisis. The client complains of nausea and joint pain, vital signs show a temperature of 102°F, heart rate of 138, and blood pressure of 80/60. Which intervention should the nurse implement first?

• A. Obtain an analgesic prescription.
• B. Infuse an intravenous fluid bolus.
• C. Administer PRN oral antipyretic.
• D. Cover the client with a cooling blanket.

Correct answer: B

Rationale: In acute adrenal crisis, the priority intervention is to infuse an intravenous fluid bolus to address the hypotension (blood pressure of 80/60) and help stabilize the client's condition. Adequate fluid volume is crucial in managing adrenal insufficiency crisis. Options A, C, and D do not directly address the hypotension and fluid volume depletion that are critical in this situation. Analgesics, antipyretics, and cooling blankets may be considered later, but the immediate focus should be on fluid resuscitation.

4. What is the first action the nurse should take when treating a 6-year-old child who stepped on a rusty nail?

• A. Cleanse the foot with soap and water
• B. Instruct the parent about tetanus boosters
• C. Apply a sterile dressing and refer for a tetanus booster
• D. Elevate the foot and wrap in a compression bandage

Correct answer: B

Rationale: The correct first action when a 6-year-old child steps on a rusty nail is to instruct the parent about tetanus boosters. This is important because stepping on a rusty nail increases the risk of tetanus infection. Choice A is incorrect as cleansing the foot comes after addressing the tetanus risk. Choice C is not the first action and should be done after addressing the immediate risk of tetanus. Choice D is not necessary as the priority is to prevent tetanus infection.

5. In monitoring tissue perfusion in a client following an above the knee amputation (AKA), which action should the nurse include in the plan of care?

• A. Evaluate closest proximal pulse.
• B. Note amount and color of wound drainage.
• C. Observe for swelling around the stump.
• D. Assess skin elasticity of the stump.

Correct answer: A

Rationale: After an amputation, monitoring the pulse closest to the stump is crucial in evaluating tissue perfusion and the overall health of the limb. Swelling and changes in perfusion can indicate complications such as blood clots or infection. Assessing the proximal pulse helps the nurse ensure adequate blood flow to the remaining limb, thereby preventing further complications. Choices B, C, and D are less directly related to monitoring tissue perfusion in this scenario and are more focused on wound healing and stump care.

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