Nursing Elites

1. The settings on a client's synchronized intermittent mandatory ventilation (SIMV) are respiratory rate 12 breaths/minute, tidal volume at 600 mL, FiO2 35%, and positive end-expiratory pressure (PEEP) 5 cm H2O. Which assessment finding necessitates immediate intervention by the nurse?

• A. Bilateral crackles in the lung bases.
• B. Low-pressure indicator alarm.
• C. Oxygen saturation of 91%.
• D. Respiratory rate of 18 breaths/minute.

Correct answer: B

Rationale: A low-pressure alarm may indicate a disconnection or leak in the system, which needs immediate intervention. Bilateral crackles in the lung bases may indicate fluid overload but do not require immediate intervention in this case. An oxygen saturation of 91% is concerning but not as urgent as a potential equipment issue. A respiratory rate of 18 breaths/minute is higher than the set rate but may not necessitate immediate intervention unless accompanied by other distress symptoms.

2. A client with a history of hypertension is admitted with a blood pressure of 220/120 mm Hg. What is the priority nursing action?

• A. Administer antihypertensive medication as prescribed.
• B. Place the client in a supine position.
• C. Obtain a detailed health history.
• D. Monitor urine output.

Correct answer: A

Rationale: Administering antihypertensive medication is the priority nursing action in this situation. The extremely high blood pressure of 220/120 mm Hg puts the client at risk of severe complications such as stroke, heart attack, or kidney damage. Lowering the blood pressure promptly is crucial to prevent these complications. Placing the client in a supine position or obtaining a detailed health history are not immediate actions needed to address the hypertensive crisis. Monitoring urine output, although important, is not the priority when the client's blood pressure is critically high.

3. The nurse assesses an adult male client 24 hours following abdominal surgery and finds that his blood pressure is 98/40 mm Hg, he is tachycardic, restless, and irritable. Which action should the nurse take first?

• A. Notify the healthcare provider of the findings.
• B. Ensure that the IV is infusing at the prescribed rate.
• C. Listen to lung sounds.
• D. Check under his back for evidence of bleeding.

Correct answer: D

Rationale: In this scenario, the nurse should first check under the client for evidence of bleeding. A blood pressure of 98/40 mm Hg, along with tachycardia, restlessness, and irritability, could indicate internal hemorrhage following abdominal surgery. Checking for bleeding under the back is crucial to rule out this life-threatening complication. Notifying the healthcare provider, ensuring IV infusion, or listening to lung sounds can be important but are secondary to ruling out immediate life-threatening conditions like internal bleeding.

4. A client with chronic kidney disease is advised to follow a low-phosphorus diet. Which food should the client avoid?

• A. Milk
• B. Apples
• C. Carrots
• D. Rice

Correct answer: A

Rationale: Correct Answer: Milk. Milk is high in phosphorus and should be avoided in a low-phosphorus diet for clients with chronic kidney disease. Choice B (Apples), C (Carrots), and D (Rice) are not significant sources of phosphorus and can be included in moderation in a low-phosphorus diet. Apples and carrots are generally considered healthy choices for most individuals, while rice is a staple food that is low in phosphorus and can be part of a renal diet.

5. Which pathology is associated with an asthma condition?

• A. Chronic dilation and inflammation of the bronchi.
• B. Recurrent spasms of the airways accompanied by edema and mucus production.
• C. Progressive loss of lung function due to destruction of alveolar walls.
• D. Infection of the lung parenchyma.

Correct answer: B

Rationale: The correct answer is B: Recurrent spasms of the airways accompanied by edema and mucus production. Asthma is characterized by bronchospasms, inflammation, swelling of the airways, and increased mucus production. This leads to airway constriction, making it difficult to breathe. Choices A, C, and D do not represent the typical pathology seen in asthma. Chronic dilation and inflammation of the bronchi (Choice A) is more characteristic of bronchiectasis, progressive loss of lung function due to destruction of alveolar walls (Choice C) is seen in conditions like emphysema, and infection of the lung parenchyma (Choice D) is more related to conditions like pneumonia.

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