Nursing Elites

1. A client with chronic obstructive pulmonary disease (COPD) is receiving home oxygen therapy. What is the most important instruction the nurse should provide?

• A. Use oxygen at the highest flow rate tolerated
• B. Avoid wearing oxygen during physical activity
• C. Do not smoke while using oxygen
• D. Store oxygen tanks in a cool, dark place

Correct answer: C

Rationale: The correct answer is C: 'Do not smoke while using oxygen.' Smoking while using oxygen can lead to a serious fire hazard, as oxygen supports combustion. This instruction is crucial to prevent potential harm to the client. Choices A, B, and D are incorrect. Using oxygen at the highest flow rate tolerated can be harmful, avoiding wearing oxygen during physical activity may limit the client's mobility unnecessarily, and storing oxygen tanks in a cool, dark place, although important, is not as critical as the instruction to avoid smoking while using oxygen.

2. The nurse is caring for a client with a tracheostomy who is on mechanical ventilation. What is the priority nursing intervention?

• A. Suction the tracheostomy as needed
• B. Ensure the tracheostomy ties are secure
• C. Provide humidified oxygen
• D. Clean any exudate around the tracheostomy site

Correct answer: A

Rationale: The priority nursing intervention for a client with a tracheostomy on mechanical ventilation is to suction the tracheostomy as needed. Suctioning is essential to maintain a clear airway and prevent respiratory distress. While ensuring tracheostomy ties are secure (choice B) is important, it is not as urgent as airway maintenance. Providing humidified oxygen (choice C) is beneficial but does not address the immediate need for airway clearance. Cleaning exudate around the tracheostomy site (choice D) is important for hygiene but takes precedence over ensuring airway patency through suctioning.

3. The healthcare provider plans to assess a newborn and check the infant's Moro reflex. What is the healthcare provider evaluating?

• A. Neurological integrity
• B. Renal functioning
• C. Thermoregulation
• D. Respiratory adequacy

Correct answer: A

Rationale: The Moro reflex is an instinctive response observed in newborns, indicating their neurological integrity. This reflex is evaluated by eliciting a startle response in the infant, involving the sudden extension and abduction of the limbs, followed by their retraction. This assessment helps in determining the proper functioning of the infant's nervous system and brain. Choices B, C, and D are incorrect as they do not relate to the evaluation of the Moro reflex. Renal functioning pertains to kidney function, thermoregulation refers to temperature control, and respiratory adequacy involves assessing breathing and oxygenation levels, none of which are evaluated through the Moro reflex.

4. The client with high blood pressure is being taught by the nurse to avoid adding salt during cooking. What effect does sodium have on blood pressure?

• A. It decreases the viscosity of blood
• B. It leads to increased fluid retention
• C. It causes vasoconstriction of the blood vessels
• D. It enhances the excretion of potassium

Correct answer: C

Rationale: The correct answer is C: 'It causes vasoconstriction of the blood vessels.' Sodium can lead to vasoconstriction, which narrows the blood vessels, increasing resistance to blood flow and subsequently raising blood pressure. Choices A, B, and D are incorrect. Sodium does not decrease blood viscosity, but it can lead to fluid retention, which increases blood volume and pressure. It does not enhance the excretion of potassium; instead, high sodium intake can lead to potassium excretion by the kidneys.

5. The nurse observes that a male client's urinary catheter (Foley) drainage tubing is secured with tape to his abdomen and then attached to the bed frame. What action should the nurse implement?

• A. Raise the bed to ensure the drainage bag remains off the floor
• B. Attach the drainage bag to the side rail instead of the bed frame
• C. Observe the appearance of the urine in the drainage tubing
• D. Secure the tubing to the client's gown instead of his abdomen

Correct answer: D

Rationale: The correct action for the nurse to implement is to secure the tubing to the client's gown instead of his abdomen. Securing the tubing to the client's abdomen can cause discomfort, trauma to the urethra, and increase the risk of infection. Attaching the drainage bag to the bed frame can lead to tension on the catheter, increasing the risk of dislodgement or trauma. Raising the bed does not address the issue of incorrect tubing securing. Observing the appearance of urine is important but secondary to ensuring proper tubing attachment.

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