Nursing Elites

1. A client with a history of asthma is admitted with shortness of breath. Which finding requires immediate intervention?

• A. Increased respiratory rate.
• B. Absence of breath sounds.
• C. Expiratory wheezes.
• D. Productive cough with green sputum.

Correct answer: B

Rationale: The correct answer is B: Absence of breath sounds. This finding can indicate a pneumothorax or severe asthma exacerbation, both of which require immediate intervention to ensure adequate ventilation and prevent further complications. Increased respiratory rate (choice A) is common in asthma exacerbations but may not always necessitate immediate intervention. Expiratory wheezes (choice C) are typical in asthma and may not always indicate a critical condition. A productive cough with green sputum (choice D) suggests a possible respiratory infection but does not warrant immediate intervention as much as the absence of breath sounds.

2. The client is receiving warfarin (Coumadin) therapy. Which statement by the client indicates a need for further teaching?

• A. I will avoid eating foods high in vitamin K.
• B. I will use a soft toothbrush and an electric razor.
• C. I will keep all appointments for blood tests.
• D. I will avoid participating in contact sports.

Correct answer: D

Rationale: The correct answer is D because participating in contact sports can increase the risk of injury and bleeding in a client receiving warfarin therapy. Warfarin is a blood thinner, and activities with a higher risk of injury should be avoided to prevent bleeding complications. Choices A, B, and C are all correct statements for a client on warfarin therapy. Avoiding foods high in vitamin K helps maintain consistent anticoagulation levels, using a soft toothbrush and an electric razor reduces the risk of bleeding gums and cuts, and keeping appointments for blood tests ensures proper monitoring of the client's international normalized ratio (INR) levels.

3. A client with a history of hypertension is admitted with acute renal failure. Which assessment finding requires immediate intervention?

• A. Blood pressure of 180/100 mm Hg.
• B. Urine output of 50 mL in 4 hours.
• C. Heart rate of 100 beats per minute.
• D. Nausea and vomiting.

Correct answer: B

Rationale: Urine output of 50 mL in 4 hours indicates oliguria, which can be a sign of worsening renal function and requires immediate intervention. In acute renal failure, maintaining adequate urine output is crucial to prevent further kidney damage and manage fluid balance. A high blood pressure reading (Option A) is concerning but may not require immediate intervention in this scenario as it could be due to the history of hypertension. A heart rate of 100 beats per minute (Option C) is slightly elevated but may not be the most critical finding at this moment. Nausea and vomiting (Option D) are important to assess but are not as urgent as addressing oliguria in a client with acute renal failure.

4. The nurse is providing discharge teaching to a client with chronic obstructive pulmonary disease (COPD). Which statement by the client indicates a need for further teaching?

• A. I will use my albuterol inhaler before exercising.
• B. I will avoid secondhand smoke.
• C. I will get a flu shot every year.
• D. I will limit my fluid intake to 2 liters per day.

Correct answer: A

Rationale: Using an albuterol inhaler before exercising is appropriate for clients with COPD to prevent exercise-induced bronchospasm.

5. A nurse is planning a community event to raise awareness about mental health. Which activity should be included to best engage participants?

• A. lectures by mental health professionals
• B. interactive workshops on stress management
• C. distribution of mental health resources
• D. screenings for depression and anxiety

Correct answer: B

Rationale: Interactive workshops on stress management should be included to best engage participants in a community event about mental health. Unlike lectures by mental health professionals, workshops actively involve participants, allowing for interaction and practical skill-building. While distributing mental health resources and providing screenings for depression and anxiety are important components, interactive workshops offer a more engaging and hands-on approach, empowering individuals with skills they can use to manage their mental health effectively.

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