Nursing Elites

1. A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickening mucus, and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self-care?

• A. Increase the daily intake of oral fluids to liquefy secretions
• B. Avoid crowded enclosed areas to reduce pathogen exposure
• C. Call the clinic if undesirable side effects of medications occur
• D. Teach anxiety reduction methods for feelings of suffocation

Correct answer: A

Rationale: Increasing fluid intake is crucial as it helps to thin mucus secretions, making them easier to expectorate. This can alleviate the client's symptoms of shortness of breath and productive cough. Option B is not the most important action in this scenario, as it does not directly address the client's respiratory distress. Option C, while important, focuses on medication side effects rather than addressing the immediate breathing difficulties. Option D, teaching anxiety reduction methods, is not the priority when the client's main concern is respiratory distress.

2. When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain?

• A. Daily weight
• B. Vital signs
• C. Level of consciousness
• D. Bowel sounds

Correct answer: A

Rationale: Corrected Rationale: Daily weight is the most important assessment to monitor fluid balance in clients with nephrotic syndrome. In nephrotic syndrome, excessive protein loss leads to fluid retention and edema. Monitoring daily weight allows the nurse to assess fluid status accurately. Vital signs, while important, may not directly reflect fluid balance changes in nephrotic syndrome. Level of consciousness and bowel sounds are not typically the primary assessments for monitoring fluid balance in clients with nephrotic syndrome.

3. In planning care for a postoperative client with hypovolemic shock, which problem is most important to include in the plan of care?

• A. Risk for infection.
• B. Risk for falls.
• C. Impaired skin integrity.
• D. Activity intolerance.

Correct answer: B

Rationale: The correct answer is B: Risk for falls. In a postoperative client with hypovolemic shock, the most crucial problem to address is the risk for falls. Hypovolemic shock can result in dizziness and weakness, making the client prone to falling. Preventing falls is essential to avoid further injury or complications. Choices A, C, and D are not the top priority in this scenario. While infection, impaired skin integrity, and activity intolerance are important concerns, preventing falls takes precedence due to the immediate risk of injury associated with hypovolemic shock.

4. The healthcare provider writes several prescriptions for a client diagnosed with hospital-acquired pneumonia (HAP) that include a combination of broad-spectrum antibiotics. Which intervention should the nurse implement first?

• A. Administer the first dose of antibiotics.
• B. Obtain a chest X-ray.
• C. Administer oxygen therapy.
• D. Collect blood specimens for culture prior to starting antibiotic therapy.

Correct answer: D

Rationale: Collecting blood specimens for culture prior to starting antibiotic therapy is the priority intervention in a client diagnosed with hospital-acquired pneumonia. This step is crucial to identify the causative organism responsible for the infection and ensure that the antibiotics prescribed are appropriate for effective treatment. Administering antibiotics before collecting cultures may interfere with the accuracy of culture results, potentially leading to inappropriate treatment. While administering the first dose of antibiotics is important, obtaining a chest X-ray and administering oxygen therapy are secondary interventions compared to identifying the causative organism through blood cultures.

5. What information should the nurse include in the teaching plan of a client diagnosed with GERD?

• A. Sleep without using pillows
• B. Opt for five small meals throughout the day instead of three full meals with no snacks
• C. Minimize symptoms by wearing loose, comfortable clothing
• D. Engage in low-impact exercises like walking or swimming

Correct answer: C

Rationale: The correct answer is C: 'Minimize symptoms by wearing loose, comfortable clothing.' Wearing loose, comfortable clothing can help reduce pressure on the abdomen, which can alleviate GERD symptoms. Option A is incorrect as sleeping without using pillows is not a recommended practice for managing GERD. Option B is incorrect because it suggests adjusting food intake to five small meals throughout the day instead of three full meals with no snacks, which may not be suitable for everyone with GERD. Option D is incorrect as avoiding participation in any aerobic exercise program is not a standard recommendation for managing GERD; in fact, engaging in low-impact exercises like walking or swimming can be beneficial.

Similar Questions