Nursing Elites

1. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which assessment 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. The use of accessory muscles is most concerning in a client with COPD receiving supplemental oxygen as it indicates increased work of breathing, requiring immediate intervention. Oxygen saturation of 90% is acceptable in a client with COPD. A respiratory rate of 24 breaths per minute is slightly elevated but not as critical as the use of accessory muscles. Inspiratory crackles may be present in clients with COPD due to underlying lung changes but do not require immediate intervention unless associated with other concerning symptoms.

2. A client who recently underwent a tracheostomy is being prepared for discharge to home. Which instruction is most important for the nurse to include in the discharge plan?

• A. Explain how to use communication tools.
• B. Teach tracheal suctioning techniques.
• C. Encourage self-care and independence.
• D. Demonstrate how to clean the tracheostomy site.

Correct answer: B

Rationale: The most important instruction for a client who recently underwent a tracheostomy is to teach tracheal suctioning techniques. Suctioning helps clear secretions and maintain an open airway, which is critical for the client's respiratory function and overall well-being. While communication tools, self-care, and cleaning the tracheostomy site are important aspects of care, ensuring proper suctioning techniques is crucial for preventing complications and ensuring the client's safety.

3. The nurse is caring for a client with a history of myocardial infarction who is experiencing chest pain. Which diagnostic test should the nurse anticipate preparing the client for first?

• A. Electrocardiogram (ECG)
• B. Chest X-ray
• C. Arterial blood gases (ABGs)
• D. Echocardiogram

Correct answer: A

Rationale: Corrected Rationale: An electrocardiogram (ECG) should be performed first to assess for cardiac ischemia in a client with a history of myocardial infarction and chest pain. An ECG provides immediate information about the heart's electrical activity, helping to identify changes indicative of cardiac ischemia or infarction. Chest X-ray (Choice B) is not the initial diagnostic test for assessing chest pain related to myocardial infarction. Arterial blood gases (Choice C) are used to assess oxygenation and acid-base balance but are not the primary diagnostic test for myocardial infarction. An echocardiogram (Choice D) may provide valuable information about cardiac structure and function, but it is not the first-line diagnostic test for acute chest pain in a client with a history of myocardial infarction.

4. A client is admitted with a diagnosis of diabetic ketoacidosis (DKA). Which clinical finding is most concerning to the nurse?

• A. Kussmaul respirations
• B. Blood glucose level of 300 mg/dl
• C. Serum potassium of 3.2 mEq/L
• D. Positive urine ketones

Correct answer: C

Rationale: The correct answer is C: Serum potassium of 3.2 mEq/L. A low serum potassium level in a client with DKA is concerning due to the risk of cardiac arrhythmias. Kussmaul respirations (choice A) are a compensatory mechanism for metabolic acidosis in DKA. A blood glucose level of 300 mg/dl (choice B) is elevated but expected in DKA. Positive urine ketones (choice D) are a classic finding in DKA and not as concerning as low serum potassium.

5. A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. Which assessment finding is most concerning to the nurse?

• A. Barrel-shaped chest
• B. Use of accessory muscles
• C. Oxygen saturation of 85%
• D. Respiratory rate of 28 breaths per minute

Correct answer: C

Rationale: An oxygen saturation of 85% is significantly low for a client with COPD and indicates hypoxemia, requiring immediate intervention. In COPD, the body's ability to oxygenate adequately is already compromised, so a saturation of 85% is particularly concerning. A barrel-shaped chest and use of accessory muscles are common findings in COPD due to chronic air trapping and increased work of breathing. While a respiratory rate of 28 breaths per minute is elevated, a low oxygen saturation is a more critical finding that necessitates prompt attention.

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