Nursing Elites

1. The nurse is reviewing a client's electrocardiogram and determines the PR interval (PRI) is prolonged. What does this finding indicate?

• A. Initiation of the impulses from a location outside the SA node
• B. Inability of the SA node to initiate an impulse at the normal rate
• C. Increased conduction time from the SA node to the AV junction
• D. Interference with the conduction through one or both ventricles

Correct answer: C

Rationale: When the PR interval is prolonged, it signifies an increased conduction time from the SA node through the AV junction. This finding is characteristic of a first-degree heart block where there is a delay in the electrical conduction at the level of the AV node. Choices A, B, and D are incorrect as they do not accurately reflect the significance of a prolonged PR interval.

2. A client with chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. 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. The use of accessory muscles in a client with COPD indicates increased work of breathing and may signal respiratory failure, requiring immediate intervention. This finding suggests that the patient is struggling to breathe effectively. Oxygen saturation of 90% is low but not critically low, while a respiratory rate of 24 breaths per minute is slightly elevated but not as concerning as the increased work of breathing indicated by the use of accessory muscles. Inspiratory crackles may be present in COPD due to underlying conditions like pneumonia but do not require immediate intervention as the use of accessory muscles does.

3. A female client has been taking a high dose of prednisone, a corticosteroid, for several months. After stopping the medication abruptly, the client reports feeling 'very tired'. Which nursing intervention is most important for the nurse to implement?

• A. Measure vital signs
• B. Auscultate breath sounds
• C. Palpate the abdomen
• D. Observe the skin for bruising

Correct answer: A

Rationale: The correct answer is to measure vital signs. Abrupt withdrawal of exogenous corticosteroids can precipitate adrenal insufficiency, potentially leading to shock. Monitoring vital signs is crucial in identifying any signs of adrenal insufficiency, such as hypotension or tachycardia. Auscultating breath sounds (choice B) may be important in other situations, such as respiratory conditions, but it is not the priority in this case. Palpating the abdomen (choice C) and observing the skin for bruising (choice D) are not directly related to the potential complications of corticosteroid withdrawal and adrenal insufficiency.

4. A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. Which intervention should the nurse implement first?

• A. Administer oxygen therapy as prescribed.
• B. Elevate the head of the bed.
• C. Assess the client's level of consciousness.
• D. Obtain a sputum culture.

Correct answer: A

Rationale: Administering oxygen therapy as prescribed is the initial priority when managing an exacerbation of COPD. In COPD exacerbations, the primary concern is hypoxemia due to impaired gas exchange. Administering oxygen helps to improve oxygenation and prevent further complications. Elevating the head of the bed can aid in breathing comfort but is not the priority over ensuring adequate oxygen supply. Assessing the client's level of consciousness is important but comes after ensuring oxygenation. Obtaining a sputum culture is relevant for identifying pathogens but is not the immediate priority in addressing hypoxemia.

5. A client who is at 10-weeks gestation calls the clinic because she has been vomiting for the past 24 hours. The nurse determines that the client has no fever. Which instructions should the nurse give to this client?

• A. Come to the clinic to be seen by a healthcare provider
• B. Increase your fluid intake and rest at home
• C. Take over-the-counter antiemetics as needed
• D. Monitor your symptoms and call if they worsen

Correct answer: A

Rationale: The correct answer is to advise the client to come to the clinic to be seen by a healthcare provider. Persistent vomiting during pregnancy can lead to dehydration, which requires medical evaluation. Choice B is incorrect because solely increasing fluid intake and resting at home may not be sufficient to address the potential dehydration and underlying causes of vomiting. Choice C is not recommended without medical evaluation, as over-the-counter antiemetics should be used under healthcare provider guidance during pregnancy. Choice D is not the best option here because with persistent vomiting and risk of dehydration, immediate medical assessment is crucial to ensure the well-being of both the client and the fetus.

Similar Questions