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. 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.

3. The nurse determines that an adult client who is admitted to the post-anesthesia care unit (PACU) following abdominal surgery has a tympanic temperature of 94.6°F (34.4°C), a pulse rate of 88 beats/minute, a respiratory rate of 14 breaths/minute, and a blood pressure of 94/68 mmHg. Which action should the nurse implement?

• A. Check the BP every five minutes for one hour.
• B. Raise the HOB 60 to 90 degrees.
• C. Ask the client to cough and deep breathe.
• D. Take the client’s temperature using another method.

Correct answer: D

Rationale: Taking the temperature using another method is essential in this situation to verify if the low reading is accurate and requires further intervention. The tympanic temperature of 94.6°F may be inaccurate due to various factors such as improper technique or environmental conditions. Checking the blood pressure every five minutes for one hour (Choice A) is not the priority in this case as the low blood pressure reading alone does not necessitate such frequent monitoring. Raising the head of the bed 60 to 90 degrees (Choice B) is not directly related to addressing the low temperature and blood pressure. Asking the client to cough and deep breathe (Choice C) is a general intervention that may not directly address the specific concern of the low temperature reading.

4. The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. What action should the nurse take?

• A. Collect the blood sample
• B. Assess radial pulse volume
• C. Apply pressure to the site
• D. Select another finger

Correct answer: A

Rationale: When the nurse observes that the distal tip of the client's finger is reddened and engorged after milking, it indicates adequate blood flow. At this point, the appropriate action is to collect the blood sample for glucose level testing. Assessing radial pulse volume (Choice B) is unrelated to the situation and not necessary. Applying pressure to the site (Choice C) may disrupt the blood sample collection process. Selecting another finger (Choice D) is not warranted as the engorgement indicates sufficient blood flow for sampling.

5. The nurse is teaching a client how to collect a sputum specimen. Which steps should the nurse instruct the client to follow when collecting sputum?

• A. Breathe deeply, followed by swallowing.
• B. Breathe deeply, followed by spitting into a cup.
• C. Breathe deeply, followed by coughing up the sputum.
• D. Breathe deeply, followed by clearing the throat.

Correct answer: C

Rationale: The correct answer is to instruct the client to breathe deeply followed by coughing up the sputum. This method ensures that the specimen is collected from the lower respiratory tract and is not contaminated by saliva. Choice A (swallowing) does not result in sputum collection, while choice B (spitting into a cup) may lead to saliva contamination. Choice D (clearing the throat) is not an effective way to collect sputum as it may involve getting rid of saliva, not sputum.

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