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 receiving discharge instructions for using a walker. Which statement indicates an understanding of the teaching?

• A. I will hire someone to trim the tree that hangs low over the stairs of my front porch.
• B. I will avoid using the walker on uneven surfaces.
• C. I will use the walker on stairs for added support.
• D. I will not need to make any changes to my home environment.

Correct answer: A

Rationale: The correct answer is A because hiring someone to trim low-hanging branches over stairs ensures home safety and reflects an understanding of walker use. This action indicates the client's awareness of potential hazards and the importance of a safe environment for walker use. Choice B is incorrect as avoiding uneven surfaces is a general safety precaution but does not directly relate to walker use and does not demonstrate an understanding of the teaching. Choice C is incorrect because using a walker on stairs is not recommended due to safety concerns such as balance and fall risks. Choice D is incorrect as making no changes to the home environment may pose safety risks when using a walker, showing a lack of understanding regarding safety precautions needed for walker use.

3. During a mass casualty event, a nurse is caring for multiple clients. Which of the following clients is the nurse’s priority?

• A. A client who received crush injuries to the chest and abdomen and is expected to die.
• B. A client who has a 4-inch laceration to the head.
• C. A client who has partial-thickness and full-thickness burns to his face, neck, and chest.
• D. A client who has a fractured fibula and tibia.

Correct answer: C

Rationale: During a mass casualty event, the priority client for the nurse is the one with partial-thickness and full-thickness burns to the face, neck, and chest. Clients with severe burns in critical areas require immediate attention due to the potential for life-threatening complications such as airway compromise, fluid loss, and infection. Crush injuries and fractures, although serious, are generally less urgent in comparison and can be managed after addressing the burns. Therefore, the client with burns to the face, neck, and chest should be the nurse's priority over the other clients described.

4. Which nursing action prevents injury to a client's eye during the administration of eye drops?

• A. Holding the tip of the container above the conjunctival sac
• B. Rinsing the eye with saline before administration
• C. Placing the client in a supine position
• D. Pressing gently on the lower eyelid to open the eye

Correct answer: A

Rationale: The correct nursing action to prevent injury to a client's eye during the administration of eye drops is to hold the tip of the container above the conjunctival sac. This technique helps to prevent direct contact between the container and the eye, reducing the risk of injury. Rinsing the eye with saline before administration (Choice B) is not a standard practice and may not necessarily prevent injury. Placing the client in a supine position (Choice C) is not directly related to preventing eye injury during eye drop administration. Pressing gently on the lower eyelid to open the eye (Choice D) is not recommended as it can potentially cause injury or discomfort to the client.

5. A client has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect?

• A. Abdominal cramping
• B. Increased thirst
• C. Elevated blood pressure
• D. Elevated heart rate

Correct answer: A

Rationale: Abdominal cramping is a common manifestation of hyponatremia (low sodium levels). When sodium levels drop, it can lead to changes in the body's water balance, affecting cell function and causing symptoms like abdominal cramping. Increased thirst (choice B) is more commonly associated with hypernatremia (high sodium levels) due to the body's attempt to dilute the excess sodium. Elevated blood pressure (choice C) and elevated heart rate (choice D) are not typically direct manifestations of low sodium levels and are more commonly seen in conditions like dehydration or shock.

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