Nursing Elites

1. A client with a history of chronic obstructive pulmonary disease (COPD) presents with increasing shortness of breath. Which assessment finding is most important for the nurse to report to the healthcare provider?

• A. Barrel-shaped chest.
• B. Use of accessory muscles to breathe.
• C. Oxygen saturation of 88%.
• D. Respiratory rate of 22 breaths per minute.

Correct answer: C

Rationale: An oxygen saturation of 88% indicates hypoxemia, which is a critical finding in a client with COPD. Hypoxemia can lead to serious complications and may require immediate intervention, such as adjusting oxygen therapy to improve oxygenation levels and prevent further respiratory distress. Monitoring and maintaining adequate oxygen saturation is crucial in managing COPD exacerbations and preventing respiratory failure.

2. What nursing intervention can help alleviate pruritus in a client with cirrhosis?

• A. Administering antihistamines
• B. Providing a high-protein diet
• C. Applying emollients to the skin
• D. Encouraging frequent baths with hot water

Correct answer: C

Rationale: Applying emollients to the skin can help alleviate pruritus in clients with cirrhosis. Emollients help soothe and moisturize the skin, reducing the discomfort associated with itching.

3. A patient with a diagnosis of deep vein thrombosis (DVT) is receiving heparin therapy. Which laboratory test should the nurse monitor to evaluate the effectiveness of the heparin therapy?

• A. Prothrombin time (PT)
• B. Partial thromboplastin time (PTT)
• C. Bleeding time
• D. Platelet count

Correct answer: B

Rationale: The correct answer is B: Partial thromboplastin time (PTT). Heparin affects the intrinsic pathway of the coagulation cascade, which is reflected by changes in the PTT. Monitoring the PTT helps ensure that the patient's blood is within the desired therapeutic range and prevents complications related to clotting or bleeding. Prothrombin time (PT) primarily assesses the extrinsic pathway and is not as sensitive to heparin therapy. Bleeding time and platelet count are not specific tests for monitoring the effectiveness of heparin therapy in DVT.

4. A client with a cold is taking the antitussive benzonatate (Tessalon). Which assessment data indicates to the nurse that the medication is effective?

• A. Reports reduced nasal discharge.
• B. Denies having coughing spells.
• C. Able to sleep through the night.
• D. Expectorating bronchial secretions.

Correct answer: B

Rationale: The correct answer is B. Denying having coughing spells indicates the effectiveness of benzonatate, an antitussive that suppresses coughing. The goal of antitussive medications like benzonatate is to reduce or eliminate coughing, so the absence of coughing spells signifies the drug's efficacy. The other options do not directly reflect the medication's intended effect and are not specific indicators of benzonatate's effectiveness.

5. A 35-year-old woman presents with abdominal pain, diarrhea, and weight loss. She has a history of recurrent mouth ulcers and a perianal fistula. What is the most likely diagnosis?

• A. Ulcerative colitis
• B. Irritable bowel syndrome
• C. Crohn's disease
• D. Diverticulitis

Correct answer: C

Rationale: The combination of symptoms including recurrent mouth ulcers, perianal fistula, abdominal pain, diarrhea, and weight loss strongly suggests Crohn's disease. These extra-intestinal manifestations are characteristic of Crohn's disease, a chronic inflammatory condition that can affect any part of the gastrointestinal tract. Ulcerative colitis primarily involves the colon, while irritable bowel syndrome is a functional disorder without the inflammatory component seen in Crohn's disease. Diverticulitis typically presents with localized left lower quadrant pain and is less likely to cause mouth ulcers and perianal fistulas.

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