Nursing Elites

1. A client with a history of gastrointestinal bleeding is taking warfarin (Coumadin). Which instruction should the nurse include in the teaching plan?

• A. Avoid eating foods high in vitamin K.
• B. Take aspirin for pain relief.
• C. Report any signs of bruising or bleeding to your healthcare provider.
• D. Limit fluid intake to 2 liters per day.

Correct answer: C

Rationale: The correct instruction for a client taking warfarin, an anticoagulant, is to report any signs of bruising or bleeding to the healthcare provider promptly. This is crucial as these symptoms may indicate over-anticoagulation, which can lead to serious complications. Monitoring for signs of bleeding is essential to adjust the medication dosage or take appropriate measures to ensure the client's safety.

2. When teaching a client with chronic obstructive pulmonary disease (COPD) about nutrition, what information should be included? (Select all that apply)

• A. Avoid drinking fluids just before and during meals.
• B. Rest before meals if experiencing dyspnea.
• C. Have about six small meals a day.
• D. Eat high-fiber foods to promote gastric emptying.

Correct answer: D

Rationale: When educating a client with COPD about nutrition, it is important to consider factors that can impact breathing and digestion. Avoiding drinking fluids just before and during meals can help prevent bloating, which may impede breathing. Resting before meals if experiencing dyspnea can aid in reducing respiratory effort during eating. Having about six small meals a day can help prevent overeating and decrease the feeling of fullness, promoting easier breathing. However, it is crucial to be cautious with high-fiber foods as they can produce gas, leading to abdominal bloating and increased shortness of breath. Clients with COPD should focus on increasing calorie and protein intake to prevent malnourishment. It is advisable not to increase carbohydrate intake as this can elevate carbon dioxide production and exacerbate breathing difficulties.

3. During pulmonary hygiene for a client with pneumonia, a nurse positions the client on his left side in Trendelenburg position. From which of the following lung segments should the nurse expect secretions to be mobilized with the client in this position?

• A. Lateral segment of the left lower lobe
• B. Lateral segment of the right lower lobe
• C. Posterior segment of the right middle lobe
• D. Posterior segment of the right lower lobe

Correct answer: B

Rationale: When a client is positioned on the left side in Trendelenburg position for pulmonary hygiene, secretions are expected to be mobilized from the lateral segment of the right lower lobe. This positioning helps facilitate drainage and clearance of secretions from this specific area of the lung, aiding in overall pulmonary hygiene and improving ventilation.

4. A client with a tracheostomy experienced a coughing spell during a meal that was being fed by an unlicensed assistive personnel (UAP). What action by the nurse takes priority?

• A. Assess the client's lung sounds.
• B. Assign a different UAP to the client.
• C. Report the UAP to the manager.
• D. Request thicker liquids for meals.

Correct answer: A

Rationale: The priority action for the nurse is to assess the client's lung sounds to check for signs of aspiration, which can compromise the client's oxygenation. This is crucial to ensure the client's immediate safety and respiratory status. Once the client has been assessed, the nurse can then consider consulting with the registered dietitian regarding appropriate thickened liquids for future meals. Assigning a different UAP or reporting the UAP to the manager may be necessary steps but not the immediate priority in this situation.

5. While assessing a client with a tracheostomy, a nurse notes that the tracheostomy tube is pulsing with the heartbeat during a pulse check. No other abnormal findings are noted. What action should the nurse take?

• A. Notify the operating room of a potential emergency case.
• B. No action is required at this time; this pulsation can be a normal finding in some clients.
• C. Remove the tracheostomy tube and ventilate the client using a bag-valve-mask.
• D. Stay with the client and ask someone else to contact the provider immediately.

Correct answer: D

Rationale: The pulsation of the tracheostomy tube with the heartbeat may indicate a tracheoinnominate artery fistula, which can lead to life-threatening hemorrhage if the artery is breached. In this scenario, as there is no active bleeding yet, the nurse should remain with the client and have another person notify the provider immediately. If the client starts to hemorrhage, the nurse should remove the tracheostomy tube and apply pressure at the bleeding site, preparing the client for urgent surgical intervention.

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