Nursing Elites

1. A client who is newly diagnosed with emphysema is being prepared for discharge. Which instruction is best for the nurse to provide the client to assist them with dyspnea self-management?

• A. Allow additional time to complete physical activities to reduce oxygen demand.
• B. Practice inhaling through the nose and exhaling slowly through pursed lips.
• C. Use a humidifier to increase home air quality humidity between 30-50%.
• D. Strengthen abdominal muscles by alternating leg raises during exhalation.

Correct answer: B

Rationale: The correct answer is B. Instructing the client to practice inhaling through the nose and exhaling slowly through pursed lips can help improve oxygenation and reduce dyspnea. This technique, known as pursed lip breathing, can help regulate breathing patterns and decrease the work of breathing in clients with emphysema. Choice A is incorrect because allowing additional time for physical activities does not directly address dyspnea management. Choice C is incorrect as using a humidifier, although beneficial for respiratory conditions, does not specifically assist with dyspnea self-management. Choice D is also incorrect as strengthening abdominal muscles through leg raises does not directly target dyspnea relief.

2. During a paracentesis, two liters of fluid are removed from the abdomen of a client with ascites. A drainage bag is placed, and 50 ml of straw-colored fluid drains within the first hour. What action should the nurse implement?

• A. Palpate for abdominal distention
• B. Send fluid to the lab for analysis
• C. Continue to monitor the fluid output
• D. Clamp the drainage tube for 5 minutes

Correct answer: C

Rationale: Continuing to monitor the fluid output is the appropriate action in this situation. Monitoring the fluid output helps the nurse assess the client's ongoing response to the procedure and detect any sudden changes, such as increased or decreased drainage rate, which could indicate complications. Palpating for abdominal distention, sending fluid to the lab for analysis, or clamping the drainage tube are not necessary actions at this point, as the priority is to monitor the client's condition post-procedure.

3. The parents of a child who has been diagnosed with sickle cell anemia ask why their child experiences pain. What is the most likely cause of the pain?

• A. Inflammation of the vessels
• B. Obstructed blood flow
• C. Overhydration
• D. Stress-related headaches

Correct answer: B

Rationale: The correct answer is B: Obstructed blood flow. In sickle cell anemia, the sickle-shaped red blood cells can clump together, obstructing blood flow in the vessels. This obstruction leads to tissue hypoxia (lack of oxygen) and necrosis, causing pain. Choice A, inflammation of the vessels, is not the primary cause of pain in sickle cell anemia. Choice C, overhydration, is unrelated to the pathophysiology of sickle cell anemia. Choice D, stress-related headaches, is not a characteristic symptom of sickle cell anemia.

4. When is the best time to administer pancreatic enzyme replacement?

• A. Before meals and snacks
• B. Before bedtime
• C. Early in the morning
• D. After meals and snacks

Correct answer: A

Rationale: The correct answer is to administer pancreatic enzyme replacement before meals and snacks. This timing is crucial as it allows the enzymes to assist in the digestion of carbohydrates, fats, and proteins that are consumed during the meals. Administering the replacement after meals and snacks would not be effective as the enzymes need to be present in the digestive system when food is consumed. Options B and C are incorrect as they do not align with the optimal timing for pancreatic enzyme replacement administration.

5. Which laboratory results should the nurse anticipate to be abnormal in a child with hemophilia?

• A. Prothrombin time
• B. Bleeding time
• C. Platelet count
• D. Partial thromboplastin time

Correct answer: D

Rationale: In a child with hemophilia, the nurse should anticipate an abnormality in the partial thromboplastin time (PTT) due to the deficiency in clotting factors. Prothrombin time, bleeding time, and platelet count are typically normal in hemophilia. Prothrombin time measures the extrinsic pathway of coagulation and is not affected in hemophilia. Bleeding time assesses platelet function, which is normal in hemophilia as the issue lies with clotting proteins, not platelets. Platelet count is also expected to be normal unless there is another underlying condition affecting platelet production or function.

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