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. The nurse is caring for a client with a tracheostomy who has thick, tenacious secretions. Which assessment finding is most concerning?

• A. Crepitus around the tracheostomy site
• B. Dry and cracked tracheostomy site
• C. Yellowing of the skin around the tracheostomy site
• D. Mucous plugging of the tracheostomy tube

Correct answer: D

Rationale: Mucous plugging of the tracheostomy tube is the most concerning finding in a client with a tracheostomy and thick secretions. This can lead to airway obstruction, which requires immediate intervention to maintain a patent airway. Crepitus around the tracheostomy site may indicate subcutaneous emphysema but does not pose an immediate threat to the airway. A dry and cracked tracheostomy site may require interventions to promote healing but is not as urgent as mucous plugging. Yellowing of the skin around the tracheostomy site could indicate infection or impaired circulation, which should be addressed but does not pose the same immediate risk as airway obstruction.

3. The charge nurse observes a new nurse preparing to insert an intravenous (IV) catheter. The new nurse has gathered supplies, including intravenous catheters, an intravenous insertion kit, and a 4x4 sterile gauze dressing to cover and secure the insertion site. What action should the charge nurse take?

• A. Instruct the nurse to use a transparent dressing over the site
• B. Allow the new nurse to proceed with the procedure
• C. Assist the new nurse with the insertion
• D. Replace the 4x4 gauze with a larger dressing

Correct answer: A

Rationale: The correct answer is to instruct the nurse to use a transparent dressing over the site. Transparent dressings allow for continuous observation of the IV site, reducing the risk of complications. Choice B is incorrect because the charge nurse should intervene to ensure the new nurse follows best practices. Choice C is incorrect as the charge nurse should not just assist but provide guidance on the correct procedure. Choice D is incorrect because the size of the dressing is not the issue; it's the type of dressing that allows for better observation.

4. A school nurse is called to the soccer field because a child has a nosebleed (epistaxis). In what position should the nurse place the child?

• A. Sitting up and leaning forward
• B. Lying flat with legs elevated
• C. Lying on the side with the head slightly raised
• D. Sitting up and tilting the head back

Correct answer: A

Rationale: The child with a nosebleed (epistaxis) should be placed in a sitting position, leaning forward, to prevent blood from flowing down the throat. This position helps to control the bleeding and prevents the child from swallowing blood, which can cause nausea or vomiting. Choice B is incorrect because elevating the legs is not recommended for nosebleeds. Choice C is incorrect because lying on the side with the head slightly raised is not the optimal position for managing a nosebleed. Choice D is incorrect because tilting the head back can lead to blood flowing down the throat and potentially cause aspiration.

5. The nurse is administering an IV medication to a client with a history of anaphylaxis. Which intervention is most important for the nurse to implement?

• A. Stay with the client throughout the infusion.
• B. Keep emergency resuscitation equipment at the bedside.
• C. Obtain the client's allergy history.
• D. Ask the client about past allergic reactions to medications.

Correct answer: B

Rationale: Keeping emergency resuscitation equipment at the bedside is crucial in case the client experiences anaphylaxis during the infusion. While staying with the client throughout the infusion (Choice A) is important, having immediate access to emergency equipment takes priority in this situation. Obtaining the client's allergy history (Choice C) and asking about past allergic reactions to medications (Choice D) are relevant but do not address the immediate need for emergency intervention in case of anaphylaxis.

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