Nursing Elites

1. A client with chronic obstructive pulmonary disease (COPD) is being discharged with home oxygen therapy. Which statement by the client indicates a need for further teaching?

• A. I will keep my oxygen tank upright at all times.
• B. I will not use petroleum jelly to keep my nose from drying out.
• C. I will not smoke or allow others to smoke around me.
• D. I will call my doctor if I have difficulty breathing.

Correct answer: B

Rationale: The correct answer is B. Petroleum jelly is flammable and should not be used with oxygen therapy due to the risk of fire. The client should avoid using petroleum-based products around oxygen equipment. Choices A, C, and D are all appropriate statements for a client with COPD receiving home oxygen therapy. Keeping the oxygen tank upright ensures proper oxygen flow, avoiding smoking or exposure to smoke helps prevent respiratory aggravation, and knowing to seek medical help promptly for breathing difficulties is essential for managing COPD effectively.

2. A client is postoperative following knee arthroplasty and requires the use of a thigh-length sequential compression device. Which of the following actions should the nurse take?

• A. Ensure two fingers can fit under the sleeves.
• B. Ensure the device is not too tight to impede circulation.
• C. Position the client comfortably before applying the device.
• D. Use the device continuously to prevent blood clots.

Correct answer: A

Rationale: The correct action for the nurse to take when applying a thigh-length sequential compression device to a postoperative client is to ensure that two fingers can fit under the sleeves. This action helps prevent the device from being too tight, which could impede circulation. Choice B is incorrect because the device should not be too tight, as it could lead to circulation issues. Choice C is incorrect as the client should be in a comfortable position, not necessarily supine. Choice D is incorrect as sequential compression devices are typically used continuously to prevent blood clots.

3. A healthcare provider is assessing a client with a diagnosis of acute pancreatitis. Which laboratory value would be most concerning?

• A. Serum amylase of 200 U/L
• B. Serum lipase of 250 U/L
• C. Blood glucose of 200 mg/dL
• D. Serum calcium of 7.5 mg/dL

Correct answer: D

Rationale: In acute pancreatitis, hypocalcemia (low serum calcium) is a critical finding that is associated with a poor prognosis and requires immediate attention. Serum amylase and lipase are typically elevated in acute pancreatitis due to pancreatic inflammation, but they are not indicators of severity. Blood glucose levels may be elevated due to stress or underlying conditions but are not directly related to the severity of acute pancreatitis. Therefore, the most concerning value in this scenario is the low serum calcium level, which can have significant implications for the client's prognosis.

4. A client who is malnourished expresses concern about losing their loose wedding ring. What is the most appropriate action for the nurse to take?

• A. I can pin it to your hospital gown to prevent it from falling off.
• B. I will place it in your drawer to keep it safe.
• C. I will hold onto it until a family member can retrieve it.
• D. I can put it in a locked storage unit for you.

Correct answer: D

Rationale: The most appropriate action for the nurse to take is to put the client's wedding ring in a locked storage unit for safekeeping. This ensures that the ring is secure and minimizes the risk of loss or damage. Choices A, B, and C do not provide the same level of security and protection as placing the ring in a locked storage unit. Pinning it to the hospital gown (Choice A) may not be secure and could still lead to loss. Placing it in the client's drawer (Choice B) may not guarantee its safety. Holding onto it until a family member retrieves it (Choice C) leaves the ring vulnerable to misplacement or theft.

5. A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure?

• A. When do you usually bathe, in the morning or evening?
• B. Do you prefer a bath or a shower?
• C. At what temperature do you prefer your bath water?
• D. Are you able to help with your hygiene care?

Correct answer: D

Rationale: The priority assessment question before beginning hygiene care for a new resident is determining if the resident is able to help with their hygiene care. This is essential to ensure the resident's safety during the procedure and prevent any potential injuries. Options A, B, and C, while relevant to providing personalized care, are not as critical as assessing the resident's ability to participate in their own hygiene care. Asking about the resident's ability to assist also promotes their independence and autonomy in self-care activities.

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