Nursing Elites

1. A client with chronic obstructive pulmonary disease (COPD) is prescribed home oxygen therapy. What teaching should the nurse provide?

• A. Ensure that the client uses oxygen continuously at night.
• B. Instruct the client to avoid smoking and exposure to smoke.
• C. Teach the client how to clean and replace the oxygen tubing.
• D. Instruct the client to increase their fluid intake.

Correct answer: C

Rationale: The correct teaching for a client with COPD prescribed home oxygen therapy is to educate them on how to clean and replace the oxygen tubing. This is crucial to prevent infections and ensure the effectiveness of the oxygen delivery system. Option A is not necessary as oxygen therapy is usually prescribed as needed, not continuously at night. While smoking cessation and avoiding smoke exposure are important in COPD management, it is not directly related to home oxygen therapy. Increasing fluid intake is beneficial for some conditions but is not specifically related to home oxygen therapy for COPD.

2. A client with deep vein thrombosis (DVT) is prescribed heparin therapy. What laboratory value should the nurse monitor?

• A. Monitor the client’s liver function tests.
• B. Monitor the client’s prothrombin time (PT).
• C. Monitor the client’s partial thromboplastin time (PTT).
• D. Monitor the client’s red blood cell count.

Correct answer: C

Rationale: The correct answer is C: Monitor the client’s partial thromboplastin time (PTT). During heparin therapy for DVT, it is essential to monitor the PTT to assess the effectiveness of the medication in preventing clot formation. Monitoring the PTT helps ensure that the client is within the therapeutic range for anticoagulation. Choices A, B, and D are incorrect because liver function tests, prothrombin time (PT), and red blood cell count are not specifically monitored to assess the effectiveness of heparin therapy in preventing clot formation.

3. During a neurologic assessment of a client with a suspected stroke, which finding is most concerning?

• A. Unilateral facial droop
• B. Slurred speech
• C. Weakness in one arm
• D. Sudden loss of consciousness

Correct answer: D

Rationale: Sudden loss of consciousness in a client with a suspected stroke is the most concerning finding as it indicates a more severe neurological event, such as brain stem involvement or hemorrhage, requiring immediate intervention. While unilateral facial droop, slurred speech, and weakness in one arm are all common signs of a stroke, sudden loss of consciousness signifies a critical condition that needs urgent attention and evaluation to prevent further complications.

4. An older client with type 1 diabetes arrives at the clinic with abdominal cramping, vomiting, lethargy, and confusion. What should the nurse implement first?

• A. Start an IV infusion of normal saline.
• B. Obtain a serum potassium level.
• C. Administer the client's usual dose of insulin.
• D. Assess the pupillary response to light.

Correct answer: A

Rationale: The correct answer is A: Start an IV infusion of normal saline. The client is showing signs of dehydration, such as abdominal cramping, vomiting, lethargy, and confusion, which can be exacerbated by hyperglycemia. Rehydration is the initial priority to address the fluid imbalance. Option B, obtaining a serum potassium level, though important in the management of diabetes, is not the immediate priority over rehydration. Option C, administering the client's usual dose of insulin, should only be done after addressing the dehydration and confirming the client's blood glucose levels. Option D, assessing the pupillary response to light, is not the most urgent intervention needed in this situation compared to rehydration to correct fluid imbalance.

5. The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine, and the UAP is placing soft pillows along the side rails. What action should the nurse take?

• A. Leave the pillows in place and document the action
• B. Inform the UAP that the pillows should be removed immediately
• C. Request that the pillows be replaced with firm padding
• D. Ensure that the side rails are padded and leave the pillows

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to inform the UAP that the pillows should be removed immediately. Soft pillows along the side rails do not provide sufficient protection during a seizure. The pillows could potentially increase the risk of injury, such as hitting the head or limbs against the hard side rails. Requesting firm padding or ensuring that the side rails are padded are not as effective as removing the pillows to prevent harm to the client. Leaving the pillows in place without addressing the potential risks would not be in the best interest of the client's safety.

Similar Questions