Nursing Elites

1. To auscultate for a carotid bruit, where should the nurse place the stethoscope?

• A. Base of the neck on the right side
• B. Above the clavicle
• C. Over the sternum
• D. Over the trachea

Correct answer: A

Rationale: To auscultate for a carotid bruit, the nurse should place the stethoscope at the base of the neck, near the carotid artery. A carotid bruit is an abnormal sound that indicates turbulent blood flow in the carotid artery, potentially due to arterial narrowing or atherosclerosis. Placing the stethoscope above the clavicle, over the sternum, or over the trachea would not provide the nurse with the optimal location to assess for carotid artery abnormalities.

2. The healthcare worker is wearing PPE while caring for a client. When exiting the room, which PPE should be removed first?

• A. Gloves
• B. Face shield
• C. Mask
• D. Gown

Correct answer: A

Rationale: Gloves should be removed first as they are most likely to be contaminated. This is followed by the gown, then face shield, and mask. Correct removal sequence helps prevent contamination. Removing gloves first reduces the risk of transferring pathogens from the gloves to other PPE or surfaces. Face shield and mask should be removed last as they protect mucous membranes from exposure to contaminants. Removing PPE in the correct sequence is crucial in preventing the spread of infections.

3. A client is experiencing acute bronchospasm. What is the nurse's priority intervention?

• A. Administer a nebulizer treatment of albuterol.
• B. Start an IV infusion of normal saline.
• C. Administer oxygen at 4L/min via nasal cannula.
• D. Position the client in a high Fowler's position.

Correct answer: A

Rationale: The correct answer is to administer a nebulizer treatment of albuterol. In acute bronchospasm, the priority intervention is to deliver a bronchodilator like albuterol to open the airways and improve breathing. Starting an IV infusion of normal saline (Choice B) may be necessary but not the priority in this situation. Administering oxygen at 4L/min via nasal cannula (Choice C) is important but not the first intervention for bronchospasm. Positioning the client in a high Fowler's position (Choice D) can help with breathing but is not the priority over administering a bronchodilator.

4. A female client with acute respiratory distress syndrome (ARDS) is sedated and on a ventilator with 50% FIO2. What assessment finding warrants immediate intervention?

• A. Assess the client’s lung sounds bilaterally.
• B. Diminished left lower lobe sounds.
• C. Monitor ventilator settings for changes in oxygen levels.
• D. Increased sputum production and shortness of breath.

Correct answer: B

Rationale: Diminished breath sounds in a sedated client with ARDS and on a ventilator indicate collapsed alveoli, which requires immediate intervention, such as chest tube insertion, to prevent further lung damage. Assessing bilateral lung sounds (Choice A) is important but not as urgent as identifying diminished sounds in a specific location. Monitoring ventilator settings (Choice C) is essential but does not directly address the immediate need for intervention due to diminished breath sounds. Increased sputum production and shortness of breath (Choice D) may indicate other issues but are not specific to the urgency of addressing diminished breath sounds in ARDS.

5. A client with diabetic ketoacidosis (DKA) is receiving an insulin infusion. Which finding indicates that the treatment is effective?

• A. Potassium level of 4.0 mEq/L.
• B. Blood glucose level of 180 mg/dL.
• C. Urine output of 50 mL/hour.
• D. Absence of ketones in the urine.

Correct answer: D

Rationale: The correct answer is D: Absence of ketones in the urine. In a client with diabetic ketoacidosis (DKA) receiving an insulin infusion, the absence of ketones in the urine indicates that ketoacidosis is resolving. This is a crucial finding as it shows that the insulin therapy is effectively addressing the metabolic imbalance causing DKA. Choices A, B, and C are incorrect: A potassium level of 4.0 mEq/L is within normal range but does not directly reflect the resolution of DKA; a blood glucose level of 180 mg/dL, while improved, is still high and does not specifically indicate the resolution of ketoacidosis; urine output of 50 mL/hour is within normal limits but does not directly point to the resolution of DKA.

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